The illness and economic costs associated with tobacco are elevated among Substance Use Disorder (SUD) treatment populations. However, individuals in SUD treatment are concerned about their smoking and evidence indicates quitting during SUD treatment does not interfere with sobriety. Too often, tobacco use is overlooked in SUD programs because staff often lack knowledge about tobacco dependence, and many incorrectly believe that quitting may jeopardize alcohol/other drug recovery. To address these and other barriers, our group has developed a model, "Addressing Tobacco Through Organizational Change" (ATTOC), to foster and support organizational changes in SUD programs related to treating tobacco dependence. The model has been tested in several non-VA settings with promising results.
To implement and evaluate ATTOC in the Domiciliary SUD program at the ENRM VAMC in Bedford, MA.
Implementation of ATTOC involved conducting a needs assessment (using our Environmental Scan instrument), working closely with program leadership, identifying a "champion" to develop goals and to specify activities for achieving goals. We also attended staff meetings and identified other effective modes of communication to engage staff in the ATTOC planning and implementation process. We conducted three staff trainings and met regularly with the champion and other stakeholders to discuss strengthening the enforcement of the medical center's current tobacco use restrictions. We also sought the support of VAMC administration with had authority over domiciliary leadership.
Implementation activities took place over a nine-month period. We used qualitative and quantitative methods to evaluate implementation efforts. We conducted two focus groups with staff and three focus groups with patients. Staff focus groups were conducted at two time points: prior to the ATTOC intervention and upon conclusion of intervention activities. Patient focus groups were conducted at three time points: prior to the ATTOC intervention, mid-point (week 12) and upon conclusion of intervention activities. We also conducted interviews with the domiciliary's senior clinical supervisor. The Environmental Scan was re-administered following intervention activities to assess success of the initiative. To complement the formative evaluation, we also collected quantitative process outcomes data on staff knowledge, attitudes and practices regarding tobacco dependence treatment.
The needs assessment we conducted prior to the intervention identified several strengths, most notably a hospital-wide tobacco leadership team and smoking cessation program, a supportive domiciliary chief and a mandatory psycho-educational group about smoking for all domiciliary residents. However, during our needs assessment, we identified mixed support among staff for encouraging veterans to quitand minimal knowledge/ training among staff about tobacco treatment and limited enforcement among domiciliary staff of the hospital's tobacco-restriction policy.
Focus groups among patients revealed that smoking-cessation was an important and worthwhile goal. However, most patients stated that quitting while dealing with other addiction and mental health problems during their domiciliary stay was not realistic. Specifically, most patients explained that they considered smoking an important stress reliever, and also noted that even if they wished to quit smoking, it would be difficult because of an enduring "smoking culture" among domiciliary residents. Further, patients explained that seeing others smoke and smelling cigarettes made it challenging to quit.
The domiciliary senior clinical supervisor strongly endorsed the notion of addressing smoking cessation alongside other substance use and mental health disorders. However, staff indicated top priority was to address substance abuse and mental health problems, and once these priorities were addressed there was little time, if any, to discuss smoking. Additionally, nurses charged with assessing a wide array of health concerns, addressed smoking more consistently than other staff. The senior supervisor noted an increase in the immediate weeks post-intervention, in staff addressing tobacco.. However, since that period, there was a decline similar to pre-intervention levels. We also observed a similar trend post-intervention, but also identified greater support from staff in enforcing the hospital's smoking restriction policy and greater attention given to tobacco in the program's policies and procedures manual. While acknowledging the challenge of integrating smoking cessation into substance abuse/mental health programs, the senior supervisor stated that addressing tobacco use will continue to be a top priority and ongoing staff encouragement will be necessary in order to address tobacco more consistently.
Quantitative data was collected on 17 (11 pre-intervention, 3 during intervention, 3 post intervention) Domiciliary residents. All participants were current smokers with 11.8% ever using chewing tobacco in their lifetime. The main reasons for tobacco use were habit (42.9%), stress reduction (35.7%), enjoyment (14.3%) and sociability (7.1%). Among participants, 82.4% were somewhat or very concerned about their tobacco use.
While patient knowledge and attitudes did not change across assessment periods, participants were more aware of community resources to quit during- and post-intervention (p = .05), No differences existed across assessment time points, but 85.7% of participants agreed cessation treatment should be offered to smokers in the program, with 50.0% identifying program entry as the most optimal time to intervene. Unfortunately, 29.4% reported that clients and program staff smoke together and 58.8% reported that staff expressed concern about the impact of smoking on their own health. Moreover, participants in the implementation and post-implementation phases were more likely to be encouraged by staff to reduce their smoking to five or fewer cigarettes per day if unable to quit (p = .04).
Quantitative data were collected from 8 (6 pre-intervention, 2 post intervention) staff during the project. Among pre-intervention staff, 28.6% never asked whether a patient smoked in the past month, while 42.9% said they usually asked. Also, 42.9% said they always advised patients who smoked to quit. Less than half (42.9%) had heard of VHA issued guidelines for treating nicotine dependence and only 28.6% said they were familiar with the guidelines'. Lack of patient material inadequate staff training, and system complexities were cited as limitations for offering cessation counseling.
The key impact of this project was to initiate a process for enhancing tobacco services to veterans served by VA domiciliaries. Staff received training in best clinical practices for addressing tobacco, more comprehensive services were delivered, procedures were put into place for enforcing medical center policies regarding smoking, and the policies and procedures manual was modified to include a greater emphasis on addressing tobacco. Project staff discussed with program leadership how changes initiated by the project could be sustained and what additional changes could be made to further enhance tobacco-related service delivery.
External Links for this Project
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