Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study
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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2020, ChestCitation Excerpt :By late 2016, we learned that we were on track to improving Tob-2 and Tob-3 metrics. Accordingly, beginning in January 2017, TTC service efforts focused on providing more comprehensive treatment to particularly vulnerable populations with high smoking rates such as those with SUD36,37; improving patient acceptance of NRT, which was approximately 50%; and improving communication with primary inpatient teams so as to increase follow-through of TTC recommendations.27 The trade-off of these more comprehensive visits was fewer consultations, which was later addressed by the hospital investing in an additional tobacco treatment specialist in 2018.
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2020, Addictive BehaviorsCitation Excerpt :Expectancies may arise from past experiences with tobacco, or they may develop for other reasons (e.g., social learning; Bandura, 1978). Individuals with SUD have reported using tobacco to manage affective states and stress levels, as well as to distract them from drug cravings (Asher et al., 2003; Bhuiyan, Jonkman, Connor, & Giannetti, 2017; Kathuria et al., 2019). Similarly, polysubstance-using smokers reported higher expectancies for poor recovery outcomes, including increases in other drug use, if they were to quit smoking (Hendricks, Peters, Thorne, Delucchi, & Hall, 2014).
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2019, Drug and Alcohol DependenceCitation Excerpt :Low rates of smoking cessation in this population have been attributed in part to several perceived barriers specific to this group of smokers. One of these barriers includes the concern that smoking cessation might jeopardize SUD treatment outcomes (Asher et al., 2003; Twyman et al., 2014; Martin et al., 2016; Kathuria et al., 2019), however, tobacco cessation may actually improve SUD treatment outcomes (Joseph et al., 1993; Prochaska et al., 2004; Reid et al., 2008; Tsoh et al., 2011). Studies specifically assessing the effect of smoking cessation on alcohol use disorder (AUD) and drug use disorder (DUD) treatment have found that tobacco use treatment can improve alcohol abstinence and may be associated with decreased drug use (Frosch et al., 2000; Shoptaw et al., 2002; Lemon et al., 2003; Friend and Pagano, 2005a,b; Kalman et al., 2006).