Elsevier

Addictive Behaviors

Volume 95, August 2019, Pages 41-48
Addictive Behaviors

Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study

https://doi.org/10.1016/j.addbeh.2019.02.017Get rights and content

Highlights

  • Cigarette use in hospitalized SUD smokers was 3-fold higher than non-SUD smokers.

  • Heroin use disorder patients described how cigarettes potentiate their heroin high.

  • Many SUD patients are turning to vaping and e-cigarettes to quit smoking.

  • Smoking-related health events motivated SUD patients to quit smoking cigarettes.

  • SUD patients perceived clinicians do not prioritize treating tobacco dependence.

Abstract

Aims

Smoking cessation may promote long-term recovery in patients with substance use disorders (SUD). Yet smoking rates remain alarmingly high in this population. Using a sequential explanatory mixed methods approach, we examined smoking rates among hospitalized patients with SUD at a large safety-net hospital, and then characterized factors associated with smoking behaviors both quantitatively and qualitatively.

Method

We abstracted data from all hospital admissions (7/2016–6/2017) and determined demographics, substance use type, and other characteristics associated with cigarette use among those with SUD. We then conducted semi-structured qualitative interviews with 20 hospitalized SUD smokers. We analyzed transcripts to characterize factors that affect patients' smoking habits, focusing on the constructs of the Health Belief Model.

Results

The prevalence of cigarette smoking among hospitalized smokers with SUD was three times higher than those without SUD. Qualitative analyses showed that patients perceived that smoking cigarettes was a less serious concern than other substances. Some patients feared that quitting cigarettes could negatively impact their recovery and perceived that clinicians do not prioritize treating tobacco dependence. Almost all patients with heroin use disorder described how cigarette use potentiated their heroin high. Many SUD patients are turning to vaping and e-cigarettes to quit smoking.

Conclusion

Hospitalized patients with SUD have disproportionately high smoking rates and perceive multiple barriers to quitting cigarettes. When designing and implementing smoking cessation interventions for hospitalized patients with SUD, policymakers should understand and take into account how patients with SUD perceive smoking-related health risks and how that influences their decision to quit smoking.

Introduction

There has been a dramatic decline in smoking rates in the United States, but less success among vulnerable populations including the less educated, the poor, and those with mental illness and substance use disorders (SUD) (Bandiera, Anteneh, Le, Delucchi, & Guydish, 2015; Jamal et al., 2016). Despite efforts to promote smoking cessation in these populations, the prevalence of smoking cigarettes among SUD individuals remains extremely high (Kalman et al., 2001; Weinberger et al., 2018; Weinberger, Funk, & Goodwin, 2016). In fact, the prevalence of cigarette smoking in the US has increased from 2002 to 2014 among those with SUD and declined among people without SUDs (Weinberger et al., 2018). While studies show promising outcomes with pharmacotherapy and/or contingency management (Apollonio, Philipps, & Bero, 2016; Nahvi, Ning, Segal, Richter, & Arnsten, 2014; Richter & Ahluwalia, 2000; Rohsenow et al., 2015; Rohsenow et al., 2017; Rohsenow, Martin, Tidey, Colby, & Monti, 2017), quit rates among SUD smokers are consistently lower than in the general smoker population (Miller & Sigmon, 2015). Not only do those with SUD smoke more heavily and have more difficulty quitting, they also have higher tobacco-related illness and mortality (Goodwin et al., 2014; Hser, McCarthy, & Anglin, 1994; Hurt et al., 1996; Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2002; Schroeder & Morris, 2010; Weinberger, Platt, Jiang, & Goodwin, 2015).

Hospital-based smoking cessation interventions offer an opportunity to engage these vulnerable patients who may not independently seek tobacco dependence treatment. Studies in addiction treatment centers show a high prevalence of cigarette smoking among SUD patients, particularly those with opioid use disorder (OUD) (Kalman, Morissette, & George, 2005). However, little is known about the prevalence of smoking in hospitalized SUD patients, particularly by SUD type. Meanwhile, although barriers to quitting cigarettes in the general population (Macnee & Talsma, 1995; Orleans, Rimer, Cristinzio, Keintz, & Fleisher, 1991; Pomerleau, Zucker, Namenek Brouwer, Pomerleau, & Stewart, 2001; Villanti, Bover Manderski, Gundersen, Steinberg, & Delnevo, 2016) and vulnerable populations (Twyman, Bonevski, Paul, & Bryant, 2014) are well described, fewer studies describe perceived barriers specific to SUD smokers nor the most effective interventions that match their needs and preferences (Asher et al., 2003; Foster, Schmidt, & Zvolensky, 2015; Martin, Cassidy, Murphy, & Rohsenow, 2016; McHugh et al., 2017).

Using a sequential explanatory mixed methods approach (Fetters, Curry, & Creswell, 2013; Ivankova, Creswell, & Stick, 2006), we first analyzed characteristics of smokers with SUD, including by specific illicit drug, compared to those without SUD, admitted to a large safety-net hospital. Guided by the Health Belief model (HBM) (Hochbaum, 1958), we then qualitatively examined perceived beliefs, attitudes, and barriers to quitting cigarettes among hospitalized SUD smokers.

Section snippets

Materials and methods

The institutional review board at Boston University Medical Campus approved this study.

Smoking rates among hospitalized patients with and without SUD

Among 16,977 unique patients admitted to the hospital, 2729 (16.1%) had at least one SUD and 4294 (25.3%) were current smokers. Documentation as using hallucinogens (n = 2), stimulants (n = 0), sedatives (n = 1), cannabis (n = 72)) either as a single diagnosis or comorbid with alcohol, cocaine, or opioids was low and therefore excluded from further analysis. Current smoking was significantly more common among patients with SUD (1758/2729, 64.4%) than without SUD (2536/14,248, 17.8%) [χ2

Conclusions

The findings of this sequential explanatory mixed methods study add to the evidence of the widening disparity in smoking behaviors among people with SUD versus those without SUD. Analyzing data from 16,977 adults admitted to a safety-net hospital, we found the prevalence of cigarette smoking to be three times higher among SUD patients than those without SUD, a pattern persisting in every subgroup analyzed. Semi-structured interviews with hospitalized SUD patients informed our understanding of

Primary source of funding

This work was supported by the Boston University Evans Center for Implementation and Improvement Sciences (CIIS) and supported in part by resources from the Edith Nourse Rogers Memorial VA Hospital.

Conflict of interest

Dr. Kathuria has consulted for Remedy Partners on relevance of codes for pulmonary services. The authors have no other conflicts of interests to disclose.

Disclaimer

The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. The funding organizations had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

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