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Outcomes Following Treatment of Veterans for Substance and Tobacco Addiction

Published:August 20, 2014DOI:https://doi.org/10.1016/j.apnu.2014.08.002

      Abstract

      Persons who use tobacco in addition to alcohol and other drugs have increased health risks and mortality rates. The purpose of this study was to evaluate the impact of participation in a tobacco cessation program on tobacco, alcohol, and other drug use in a population seeking treatment for substance use disorders (SUDs). Tobacco, alcohol, and other drug use were assessed by urine drug screens, breathalyzer readings, and self-report. Veterans (N = 137) with a tobacco use disorder enrolled in inpatient program for the treatment of SUDs at the Salem Veterans Affairs Medical Center participated in tobacco cessation education as part of their treatment programming. Use of tobacco, drugs and/or alcohol was evaluated upon admission, 2 weeks following admission, at discharge and 1 month following graduation. The 1-month follow-up rate was 70.8%, with 97 veterans completing the follow-up assessment. Of those 97 veterans, 90.7% (n = 88) reported abstinence from alcohol and 91.8% (n = 89) reported abstinence from other drugs of abuse. Fourteen veterans (14.4%) reported abstinence from tobacco at the 1-month follow-up. The veterans reporting abstinence from tobacco use also reported abstinence from alcohol and other drugs at the 1-month follow-up.
      While the prevalence of smoking is declining in the general population, this decline is not seen in those suffering with mental illnesses, particularly, those with schizophrenia (
      • Evins A.E.
      • Cather C.
      • Deckersbach T.
      • Freudenreich O.
      • Culhane M.
      • Olm-Shipman C.M.
      • Rigotti N.
      A double-blind placebo-controlled trial of bupropion sustained-release for smoking cessation in schizophrenia.
      ). In a nationally representative U.S. sample,
      • Lasser K.
      • Boyd J.W.
      • Woolhandler S.
      • Himmelstein D.U.
      • McCormick D.
      • Bor D.H.
      Smoking and mental illness: A population-based prevalence study.
      found that individuals with a mental illness are nearly twice as likely to smoke as persons without a mental illness, purchasing approximately 45% of the tobacco products sold in the U.S. today.
      The Substance Abuse and Mental Health Services Association (
      • Substance Abuse and Mental Health Services Administration
      New frontiers in smoking cessation to support wellness among people with mental health problems.
      ) reports that among the general population, tobacco use in persons suffering with schizophrenia ranges from 62% to 90%, bipolar disorder 51% to70%, major depression 36% to 80%, anxiety disorders 32% to 60%, PTSD 45% to 60%, attention deficit hyperactivity disorder 38% to 80%, alcohol abuse 34% to 80%, and other addictions 49% to 98% (
      • Beckham J.
      • Roodman A.
      • Shipley R.
      • Hertzberg M.
      • Cunha G.
      • Kudler H.
      • Fairbank J.A.
      Smoking in Vietnam combat veterans with post-traumatic stress disorder.
      ,
      • Grant B.F.
      • Hasin D.S.
      • Chou P.
      • Stinson F.S.
      • Dawson D.A.
      Nicotine dependence and psychiatric disorders in the United States.
      ,
      • Lasser K.
      • Boyd J.W.
      • Woolhandler S.
      • Himmelstein D.U.
      • McCormick D.
      • Bor D.H.
      Smoking and mental illness: A population-based prevalence study.
      ,
      • Ziedonis D.M.
      • Kosten T.R.
      • Glazer W.M.
      • Frances R.J.
      Nicotine dependence and schizophrenia.
      ).
      Given the high rate and severity of tobacco dependence among psychiatric patients this is a serious issue for the Veterans Administration (VA) health care system, which is the largest provider of behavioral health care in the nation (
      • VA (Department of Veterans Affairs)
      ). Of all the veterans receiving treatment within the VA system, 25 to 40 percent have a psychiatric disorder (
      • Veterans Health Administration
      Integrating tobacco cessation treatment into mental health care: Conference Summary, May 4-5, 2006.
      ). Many veterans with psychiatric disorders, particularly seriously mentally ill veterans, have high morbidity and mortality rates, which are often related to tobacco-caused illnesses (
      • Cradock-O’Leary J.
      • Young A.S.
      • Yano E.M.
      • Wang M.
      • Lee M.L.
      Use of general medical services by VA patients with psychiatric disorders.
      ). As a result, many individuals with mental illness or addiction will likely die of medical disorders caused by tobacco use (
      • Hurt R.D.
      • Offord K.P.
      • Croghan I.T.
      • Gomez-Dahl L.
      • Kottke T.E.
      • Morse R.M.
      • Melton L.J.
      Mortality following inpatient addictions treatment.
      ).
      This research examined the effects of participation in tobacco cessation education on tobacco, alcohol, and other drug use in a sample of veterans who sought treatment for substance use disorders (SUDs). The transtheoretical model (
      • Prochaska J.O.
      • DiClemente C.C.
      Stages and processes of self-change of smoking: Toward an integrative model of change.
      ) provided the theoretical framework for the study. This intervention was predicted to improve substance use outcomes for veterans enrolled in the Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) Tobacco Cessation Group. Measurements included the stage of change for tobacco use, workbook progression, pharmacotherapy used, pharmacotherapy adherence, urine drug screens and breathalyzer tests, and self-report of tobacco, alcohol, and other drug use.

      The Substance Abuse Program

      The SARRTP is a 28-day residential treatment program that immerses veterans in psychosocial interventions including cognitive–behavioral therapy, brief advice and education, motivational and stage-based interventions, relapse prevention and skill-based and behavioral strategies (a complete description of the program may be obtained from the first author). Veteran's self-select group programs for participation which include introduction to 12-step, pain management, cognitive rehabilitation, dealing with depression, mental health and recovery, mindfulness, recreation therapy, life skills training, goal setting, relationship building, family therapy, wellness education, and more. Veterans are encouraged to work with their case manager and treatment team in order to choose groups that are most appropriate for their treatment goals.

      The Tobacco Cessation Program

      The SARRTP Tobacco Cessation Group met three times weekly for 30 minutes each session. Topics were presented in a structured workbook format, allowing each participant to cover the entire workbook during his or her stay in the 28-day program. Workbook progression was documented in the electronic medical record. Topics discussed in the Tobacco Cessation Program included the health benefits of tobacco cessation, personal reasons for tobacco cessation, coping with triggers, breathing techniques for stress management, strategies to reduce smoking, quit date preparation, weight management strategies, exercise tips, identifying supportive people, dealing with slips and relapse, and medications for tobacco cessation. By identifying the relationship between a person's tobacco use and substance use, patients are able to identify associations and triggers. Pharmacotherapy was also provided during treatment and following completion of the program.

      Methods

      Veterans (N = 137) were included in the study if they were 1) admitted to the Salem Veterans Affairs Medical Center's SARRTP from May 1, 2012 through December 31, 2012.; and 2) reported tobacco use within 1 month prior to admission to the program. Participants (N = 137) were between the ages of 24 and 70 with a mean age of 48.41 (SD = 11.30). The majority (96%) of participants were male. Fifty-seven percent of the sample was identified as Caucasian, 42% as African American, 1% as Hispanic and 1% as “other.” Eighty-four percent of the sample was diagnosed with an alcohol use disorder, and 78% was diagnosed with drug use disorder. Fifty-eight percent had a co-occurring non-SUD Axis I diagnosis (see Table 1 for detailed sociodemographic information).
      Table 1Baseline Characteristics (n = 137).
      CharacteristicsN%
      GenderMale13195.6
      Female64.4
      RaceAfrican American5741.6
      Caucasian7856.9
      Hispanic10.7
      Other10.7
      Marital statusNever married2316.8
      Married2417.5
      Separated2216.1
      Divorced6245.3
      Widowed64.4
      Education9th grade or less75.1
      Some high school3424.8
      High school graduate4532.8
      Some college/technical4331.4
      Bachelors degree75.1
      Masters degree10.7
      Psych DxYes8058.4
      No5741.6
      Drug DxYes10778.1
      No3021.9
      Alcohol DxYes11583.9
      No2216.1
      Demographic and baseline descriptive variables were compared for those who completed the 1-month follow-up (n = 97) to those who did not (n = 40). Chi-squares were used to compare categorical variables, and independent t-tests were used to examine continuous variables. No statistically significant differences were found for any of the variables examined.
      Diagnostic information for substance use and other mental health disorders were obtained from the electronic medical records of each veteran admitted to SARRTP. All veterans who used tobacco were enrolled in the tobacco cessation group, whether they intended to quit using tobacco or not. Data collection included percentage of days abstinent from tobacco, drugs and/or alcohol at points on admission, 2 weeks following admission, discharge and 1 month follow-up as determined by urine drug screens, breathalyzer readings, and self-report.

      Results

      Stages of Change

      Prior to admission, 43 (31.4%) veterans stated that they had no interest in quitting tobacco. At graduation, that number changed to 13 (11.2%) veterans still expressing no interest in quitting smoking. At 1 month follow-up, there was an increase to 24 (24.7%) veterans who once again decided that they were not interested in quitting tobacco. The number of veterans in the precontemplation stage of tobacco cessation decreased from 31.4% to 24.7%. At the 1 month follow-up visit, 20 (20.6%) veterans were in the action stage of tobacco cessation (see Table 2 for further details).
      Table 2Stage of Change for Quitting Tobacco.
      Baseline2-weeksDischargeFollow-up
      (n = 137)(n = 121)(n = 116)(n = 97)
      Precontemplation43 (31.4%)14 (11.6%)13 (11.2%)24 (24.7%)
      Contemplation42 (30.7%)25 (20.7%)19 (16.4%)23 (23.7%)
      Preparation47 (34.3%)69 (50.4%)70 (60.3%)30 (30.9%)
      Action5 (3.6%)13 (10.7%)14 (12.1%)20 (20.6%)
      Maintenance0 (0.0%)0 (0.0%)0 (0.0%)0 (0.0%)

      Co-occurring Mental Illness

      Of the 137 veterans enrolled in this study, 58.4% (n = 80) were diagnosed with a co-occurring mental health diagnosis. The most prevalent diagnosis was PTSD (n = 35) followed by major depressive disorders (n = 28), schizophrenia (n = 8), bipolar disorder (n = 6), and anxiety disorder (n = 3). Of the 97 veterans noted at follow-up, 53 had a co-morbid mental health diagnosis. Of those veterans, 49 abstained from alcohol and other drugs of abuse, and 11 had abstained from alcohol, other drugs of abuse and tobacco. Twenty-four veterans with co-occurring mental health diagnoses were lost to follow-up.

      Workbook Progression

      One hundred percent of the participants completed the workbook. There are twelve sections, each one covered on one of the 12 days the group meets during admission to SARRTP. Assignments were given to veterans who missed any groups due to conflicting appointments or illness. Veterans were encouraged to keep their workbooks following graduation to be used as tools for relapse prevention for tobacco, alcohol and other drugs of abuse.

      Medication Adherence

      In the month prior to entering treatment 32.1% (n = 44) of participants reported that they were prescribed pharmacotherapy, and only 2 participants (4.5% of the 44) reported that they did not adhere to taking them as prescribed. Two weeks following admission, 68.6% (n = 83) reported that they were prescribed pharmacotherapy, and 100% of those reported using it as prescribed. For the 2 weeks prior to discharge 77.6% (n = 90) reported that they were prescribed pharmacotherapy, and 100% of those reported using it as prescribed. At the 1-month follow up, 69.1% (n = 67) reported that they were prescribed pharmacotherapy and all, but 3 participants (4.5% of the 67) reported using it as prescribed.
      Upon graduation, veterans interested in quitting tobacco were prescribed a 4 week supply of nicotine patches with instructions to call for the next step down in patch dosing. Short-acting NRT in the form of gum and lozenges was also prescribed with three refills for each since this is most commonly used for either supplementation of the patch or reduction in smoking. A closer look at the individuals that quit tobacco (n = 14) shows that 7 veterans used combination therapy, 1 used patch only, 2 used gum alone, 3 used lozenges alone and 1 used no medication. Three veterans in this study were prescribed varenicline. One of those veterans stopped the medication due to troublesome dreams and insomnia. The two that continued the medication successfully quit smoking and remained abstinent from alcohol and other drugs of abuse.

      Biomarkers and Self-Report

      Urine drug screens and breathalyzers were obtained throughout the program and during aftercare visits. All urine drug screens and breathalyzers on participants in this study were negative during SARRTP admission since a positive screen results in discharge from SARRTP. At the 1-month follow-up, breathalyzers and urine drug screens were obtained during aftercare visits on 54 of the 97 veterans interviewed. The remaining 43 veterans provided only self-report data at the 1-month follow-up. Of the 10 veterans reporting use of alcohol and/or other drugs of abuse, only 4 were validated by urine drug screen. The other 6 veterans self-reported their use of both alcohol and/or other drugs of abuse. There were no positive breathalyzers.

      Alcohol and Other Drug Use

      In order to examine changes in the percentage of days of alcohol and other drug use, t-tests were performed that compared the month prior to treatment to the month following treatment. Time during treatment was not examined because all participants abstained from alcohol and other drugs while in treatment. There was a significant reduction in the days of alcohol use over time (t (96) = 7.90, p < .000; baseline M = 33.1%, SD = 32.9%; follow-up M = 4.2%, SD = 18.3%). Similarly, there was a significant reduction in days of drug use over time (t (96) = 7.16, p < .000; baseline M = 29.0%, SD = 33.2%; follow-up M = 4.0%, SD = 18.3%). Abstinence rates increased significantly from baseline to follow-up for alcohol and other drug use (see Table 3). At baseline, 25.8% of the sample reported abstinence from alcohol, and at follow-up 90.7% of the sample reported abstinence from alcohol (p < .000). At baseline, 34.0% of the sample reported abstinence from other drugs, and at the 1-month follow-up 91.8% reported abstinence from other drugs (p < .000).
      Table 3Abstinence Outcomes.
      Baseline2-weeksDischargeFollow-up
      (N = 137)(n = 121)(n = 116)(n = 97)
      VariableAbstainedUsedAbstainedUsedAbstainedUsedAbstainedUsed
      Alcohol23.4%(n = 32)76.6%(n = 105)100.0%(n = 121)0.0%(n = 0)100.0%(n = 116)0.0%(n = 0)90.7%(n = 88)9.3%(n = 9)
      Other drugs32.1%(n = 44)67.9%(n = 93)100.0%(n = 121)0.0%(n = 0)100.0%(n = 116)0.0%(n = 0)91.8%(n = 89)8.2%(n = 8)
      Tobacco0.0%(n = 0)100.00%(n = 137)8.3%(n = 10)91.7%(n = 111)11.2%(n = 13)88.8%(n =103)14.4%(n = 14)85.6%(n = 83)

      Tobacco Use

      An analysis of variance (ANOVA) with repeated measures using the Greenhouse–Geisser correction was computed. The mean days of tobacco use were not found to differ significantly over time (F(1.68, 161.23) = 2.79, p = .074). For tobacco, abstinence increased from 0.0% at baseline to 14.4% at the 1-month follow-up (see Table 4).
      Table 4Means and Standard Deviations for Percentage of Days of Use.
      Baseline2-weeksDischargeFollow-up
      (N = 137)(n = 121)(n = 116)(n = 97)
      VariableMeanSDMeanSDMeanSDMeanSD
      % of days alcohol used30.9231.430.00--0.00--4.2218.32
      % of days drug used27.4732.600.00--0.00--4.0018.25
      % of days tobacco used85.5122.9683.2528.1788.2831.6980.9135.40
      Fourteen veterans of the 137 enrolled in this study abstained from alcohol, drugs of abuse, and abstained from tobacco use during the 1-month follow-up. A closer look at these veterans reveals that at 1-month follow-up, twenty veterans were in the action stage of change, with 14 having succeeded with complete tobacco cessation. Eleven of these 14 veterans had co-occurring mental health diagnoses.

      Discussion and conclusions

      This study examined the impact of a residential treatment program for SUDs that included a formal tobacco cessation component on veterans who reported both the use of drugs/alcohol and tobacco.
      At the 1-month follow-up, 90.7% (n = 88) of the remaining sample abstained from alcohol, and 91.8% (n = 89) abstained from other drugs of abuse.
      • Lash S.J.
      • Burden J.L.
      • Parker J.D.
      • Stephens R.S.
      • Budney A.J.
      • Horner R.D.
      • Datta S.
      • Jeffreys A.S.
      • Grambow S.C.
      Contracting, prompting and reinforcing substance use disorder continuing care.
      reported abstinent rates from two residential programs (n = 183) within the VA and found 114/165 (65%) of veterans abstinent at 2 months following graduation, 86/168 (51%) at 6 months from admission, and 78/161 (48%) at 12 months following admission.
      • Moos R.H.
      • Finney J.W.
      • Ouimette P.C.
      • Suchinsky R.J.
      A comparative evaluation of substance abuse treatment: I. Treatment orientation, amount of care, and 1-year outcomes.
      found in a large representative VA sample that abstinence rates at the 3-month period were 40%.
      Prochaska's Transtheoretical Model and Bandura's Self-Efficacy model (
      • Bandura A.
      Self-efficacy: Toward a unifying theory of behavioral change.
      ) are the two most frequently cited theoretical models in nursing research (
      • O’Connell K.A.
      Theories in nursing research on smoking cessation.
      ). Nursing contributions to theory building may help us understand tobacco dependence and the factors influencing nicotine addiction. In fact, many nurses are now taking a more holistic nursing perspective to the behavior of tobacco use, examining biological models of addiction (
      • Ahijevych K.
      Biological models for studying and assessing tobacco use.
      ,
      • Institute of Medicine (IOM)
      The future of nursing: Leading change, advancing health.
      ), incorporating them into the theoretical models familiar to nurses.
      The majority of veterans admitted to SARRTP who used tobacco were either in the precontemplation or contemplation stages of change on admission. At discharge, the number of veterans in either of these stages of change had dropped, and over half (60.3%) were in the preparation stage of change concerning tobacco use cessation. Many of the veterans enrolled in this study were able to progress from a stage of precontemplation to preparation and action regarding their tobacco use through open discussion about addiction. By learning new strategies to successfully overcome their addictions, 20.6% (n = 20) of the 97 veterans located at 1-month follow-up were in the action stage of tobacco cessation, and another 30.9% (n = 30) were in the preparation stage.
      Thirty-five of the 137 (26%) veterans enrolled in this study had co-occurring PTSD.
      • Fu S.S.
      • McFall M.
      • Saxon A.J.
      • Beckham J.C.
      • Carmody T.P.
      • Baker D.G.
      • Joseph A.M.
      Post-traumatic stress disorder and smoking: A systematic review.
      note that PTSD is strongly associated with tobacco use and nicotine dependence. For tobacco users with PTSD, abstinence improves when tobacco cessation interventions are woven into standard mental health care because of the supportive counseling and mood management strategies taught as part of PTSD therapy along with the therapeutic relationship that develops over time (
      • McFall M.
      • Saxon A.J.
      • Thompson C.E.
      • Yoshimoto D.
      • Malte C.
      • K. Straits-Troster
      • Steele B.
      Improving the rates of quitting smoking for veterans with posttraumatic stress disorder.
      ). Within the SARRTP there were several groups designed to support the recovery of veterans with co-morbid mental health diagnoses including Seeking Safety, a group designed for veterans with PTSD, and Mental Health and Recovery Group for the seriously mentally-ill veteran. Relapse prevention strategies were woven into the curriculum of these groups. Tobacco cessation was encouraged throughout all aspects of substance abuse treatment with individual case management counseling sessions and treatment team meetings including tobacco cessation as part a healthy lifestyle free of addiction. However, 28 days may not be enough time to focus upon quitting tobacco along with other substances of abuse, given the emphasis on drug and alcohol treatment during the intensive treatment program. The accompanying symptoms of withdrawal that so frequently exist, especially in the first several days of substance abuse treatment, contribute to the stress and negative mood often seen in co-occurring mental illness and substance abuse. A continuum of care in the recovery process must exist as veterans transition from inpatient substance abuse treatment to outpatient mental health care.
      The observations noted in this study indicate that the use of short acting nicotine replacement works well for veterans in the preparation and action stages of change since they are able to quench the biological craving of nicotine with a fast acting nicotine replacement agent such as gum or the lozenge. Veterans in the action stage of change are also well suited for nicotine patches, bupropion, and Chantix since these medications are long acting and require daily or twice daily dosing. This blending of both the identification of the stage of change with the appropriate pharmacotherapy can serve to increase the success of an individual's cessation efforts during substance abuse treatment.
      The type of pharmacotherapy prescribed was not limited to nicotine replacement therapy. Medications such as wellbutrin and varenicline were also prescribed though not to the extent of NRT due to the presence of contraindications such as a history of seizures, recent head trauma, or mental illness. Varenicline is classified as a tobacco deterrent, producing agonist activity, preventing nicotine from binding with receptors. As a result, it reduces craving and intensity of withdrawal and reduces the sense of satisfaction from tobacco use (
      • Feigenbaum J.C.
      Pharmacological aids to promote smoking cessation.
      ,
      • Stahl S.M.
      Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications.
      ). Because of varenicline's effects on the brain's reward circuitry, it may affect mood, sometimes causing depression, suicidal or homicidal thoughts, and therefore is prescribed with close monitoring and certain restrictions within the VA. There were 3 veterans prescribed with varenicline in this study.
      Wellbutrin (bupropion SR) is a dopamine reuptake inhibiter that blocks the neural reuptake of dopamine and norepinephrine thereby reducing the craving for nicotine and the intensity of the withdrawal. It is also an antidepressant (
      • Feigenbaum J.C.
      Pharmacological aids to promote smoking cessation.
      ,
      • Stahl S.M.
      Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications.
      ). Since bupropion can lower the seizure threshold it is contraindicated in persons with any history of seizures, history of heavy alcohol use, history of eating disorders. Clinicians should exercise caution in patients with a history of severe head trauma. There were no veterans prescribed bupropion for tobacco cessation in this study.
      Self-report data on tobacco, alcohol, and other drug use were collected at each assessment point throughout the study. Biomarkers, including urine drug screens and breathalyzers, were collected at admission, regularly during treatment, and at the 1-month follow-up for veterans who attended aftercare appointments. Tobacco use was assessed using self-report with no biomarkers. Of the 97 veterans who completed the 1-month follow-up assessment, 4 (4%) positive urine drug screens were noted and 6 (6%) veterans self-reported use. At 1 month follow-up, 14 (14%) veterans reported abstinence from tobacco.
      A recent study of tobacco cessation within the Department of Veterans Affairs shows that self-report of tobacco use is not always a reliable tool for the assessment of tobacco cessation among veterans with misclassification rates among self-reported quitters around 1 in 5 (
      • Noonan D.
      • Jiang Y.
      • Duffy S.A.
      Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs.
      ). This is especially true among veterans coping with mental illness perhaps due to the social stigma surrounding tobacco use in this population (
      • Gorber S.C.
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      • Hardt J.
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      • Tremblay M.
      The accuracy of self-reported smoking: A systematic review of the relationship between self-reported and cotinine-assessed smoking status.
      ).
      There exists much epidemiological research on tobacco use, one of many health-related behaviors studied for which self-report without biological verification is relied upon (
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      ). The
      • Centers for Disease Control (CDC)
      Vital signs: Current cigarette smoking among adults aged ≥ 18 years with mental illness- United States, 2009–2011.
      acknowledges that while studies of self-reported smoking may result in lower estimates than those using biomarkers, it is unlikely that underreporting would substantially change the estimates reported. This is due in part to a comparison to estimates from other national surveys with even lower estimates of tobacco use (
      • Substance Abuse and Mental Health Services Administration
      Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11–4658.
      ,
      • Substance Abuse and Mental Health Services Administration
      Tobacco use cessation during substance abuse treatment counseling.
      ).
      Abstinence rates increased significantly from baseline to follow-up for alcohol and other drug use. The preponderance of evidence shows that tobacco cessation does not compromise abstinence (
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      Alcohol dependence and tobacco use co-occur at high rates.
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      noted that approximately 80% of people with alcoholism are nicotine dependent. It has also been found that individuals that use tobacco have two to three times the risk of non-tobacco users to have alcohol dependence (
      • Breslau N.
      Psychiatric comorbidity of smoking and nicotine dependence.
      ). Addressing the two addictions concurrently is important since research consistently shows that cross-cue reactivity such as seeing or smelling an alcoholic beverage can increase smoking urges (
      • Cooney J.L.
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      ,
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      ,
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      ). Inversely, continued smoking may increase the risk of relapse to alcohol (
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      • Hansen W.B.
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      ).
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      found that 75 percent of substance-dependent individuals accept concurrent tobacco treatment and inclusion of tobacco use treatment does not appear to reduce an individual's commitment to broader addiction treatment (
      • Sharp J.R.
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      • Novak S.
      Targeting nicotine addiction in a substance abuse program.
      ,
      • Monti P.M.
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      ).
      On average, compared with tobacco users that do not abuse substances, individuals with substance use disorders, especially alcohol dependence, are more addicted to nicotine, smoke cigarettes in greater quantities with higher nicotine contents, and have higher measures of nicotine dependence as determined by carbon monoxide assessments and Fagerstrom scores (
      • Burling A.S.
      • Burling T.A.
      A comparison of self-report measures of nicotine dependence among male drug/alcohol-dependent cigarette smokers.
      ). Research also indicates that up to 80 percent of people in addiction treatment are interested in quitting smoking (
      • Flach S.D.
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      ,
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      • McGuffin R.
      • Walker R.
      An open trial of transdermal nicotine replacement therapy for smoking cessation among alcohol- and-drug-dependent inpatients.
      ,
      • Seidner A.L.
      • Burling T.A.
      • Gaither D.E.
      • Thomas R.G.
      Substance-dependent inpatients who accept smoking treatment.
      ). Smoking prevalence is high among adults with any mental illness, especially for younger adults (<45 years of age), those with low levels of education, and those living below the poverty level (
      • Centers for Disease Control (CDC)
      Vital signs: Current cigarette smoking among adults aged ≥ 18 years with mental illness- United States, 2009–2011.
      ). This is similar to the findings in this study.
      In this sample approximately half of the veterans were diagnosed with PTSD or depression. Research has shown that factors such as frequency of therapeutic encounters, the therapeutic relationship, integrated care within the context of ongoing mental health treatment, and therapeutic interventions including cognitive behavioral therapy, mood management and medication management all contribute to successful tobacco cessation by individuals suffering from PTSD and depression (
      • Fu S.S.
      • McFall M.
      • Saxon A.J.
      • Beckham J.C.
      • Carmody T.P.
      • Baker D.G.
      • Joseph A.M.
      Post-traumatic stress disorder and smoking: A systematic review.
      ,
      • McFall M.
      • Saxon A.J.
      • Thompson C.E.
      • Yoshimoto D.
      • Malte C.
      • K. Straits-Troster
      • Steele B.
      Improving the rates of quitting smoking for veterans with posttraumatic stress disorder.
      ). While it is encouraging to see veterans progressing from a stage of precontemplation to that of preparation during the 28-day stay in SARRTP, ongoing support for tobacco cessation needs to continue within outpatient mental health treatment in order to help veterans advance towards the action and maintenance stage of change concerning tobacco use.

      Limitations and Strengths of the Study

      This descriptive study employed convenience sampling, and therefore, it is possible that other events besides the smoking intervention may account for decreases in substance use and smoking rates. For instance, completing the SARRTP alone may account for these changes. The study was not blinded; however, none of the testing (urine drug screens and breathalyzer analyses) was performed by the investigator. There was no biochemical validation of self-reported tobacco cessation, so use may have been underreported due to the relationship existing between the patient and the interviewer, otherwise known as social desirability bias (
      • Brigham J.
      • Lessov-Schlaggar C.N.
      • Javitz H.S.
      • Drasnow R.R.
      • Tildesley E.
      • Andrews J.
      • Hops H.
      • Swan G.E.
      Validity of recall of tobacco use in two prospective cohorts.
      ). There also exists the possibility of falsely elevated self-reported abstinence rates at follow-up from alcohol and other drugs of abuse since there was no biochemical validation of self-reports.
      The strengths of this study included the provision of integrated care for nicotine dependence within a substance abuse treatment program provided for veterans admitted to SARRTP. The study involved a large, diagnostically diverse sample and longitudinal data collection. The study monitored stages of change throughout admission and was able to identify progress over the course of treatment from the stage of precontemplation to that of preparation or action in this sample of veterans. The results of this study may possibly serve as a model for the development of integrated tobacco cessation programming during SARRTP programs throughout the VA.
      With tobacco use being the leading cause of preventable morbidity and mortality both in the United States and worldwide (
      • World Health Organization (WHO)
      Mortality attributable to tobacco.
      ), tobacco control should receive high priority throughout healthcare education, research, policy development and leadership. The
      • Institute of Medicine (IOM)
      Combating tobacco use in military and veteran populations.
      report highlights the problems of substance abuse that currently exist within the military, especially noting the increase in prescription drug abuse. The VA will provide care for many of these people as they transition from military to civilian life as veterans. Many of these same veterans are tobacco users.
      In order to meet the Healthy People 2020 (
      • U.S. Department of Health and Human Services
      Office of Disease Prevention and Health Promotion.
      ) target of reducing the prevalence of cigarette smoking among adults to ≤ 12% (objective TU-1), an emphasis needs to occur among the mentally ill subpopulations where the greatest tobacco consumption exists. The findings of this study support the IOM and Healthy People 2020 reports, demonstrating the need for integrated care, addressing the cessation of all addictive substances at the same time and promoting a healthy lifestyle.
      Additional research must focus on nurse led interventions for tobacco dependence treatment, evaluating advances in telehealth and other methods of outreach for rural veterans. The impact of unit-based nurse led tobacco cessation programs within medical centers, and outpatient clinics should be evaluated. The clinical reminder system within the VA is designed to allow all health care providers to assess and treat tobacco dependence, adding veteran's health care provider as a cosigner for pharmacotherapy. This aspect of the reminder system is under-utilized by nurses and needs to be promoted.
      One of the major findings of this study was that veterans participating in substance abuse treatment are interested in tobacco cessation and can progress from a stage of precontemplation (not interested in quitting tobacco) on admission to substance abuse treatment to a stage of contemplation or even preparation towards a tobacco-free life. This treatment program provided intensive tobacco cessation counseling and, yet only 14 of the 137 veterans enrolled actually quit using tobacco. This finding underscores the powerful grip tobacco dependence has upon veterans in substance abuse treatment. More research must be done to develop effective tools for the treatment of this addiction. It is time to embrace the need for substance abuse programming that includes abstinence from alcohol, illicit drug use, and tobacco use.
      The majority of published research indicates that participating in tobacco cessation efforts during substance abuse treatment will not negatively affect abstinence rates from alcohol and other drugs (
      • Fogg B.
      • Borody J.
      The impact of facility no smoking policies and the promotion of smoking cessation on alcohol and drug rehabilitation program outcomes: A review of the literature.
      ), in fact, participation in tobacco cessation efforts has been found to increase long term abstinence rates by as much as 25% in civilian populations (
      • Prochaska J.L.
      • Delucchi K.
      • Hall S.M.
      A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery.
      ). In this study, there was no comparison condition, so conclusions about causation cannot be drawn regarding alcohol, other drug, or tobacco use outcomes. However, the findings appear consistent with previous research in that the tobacco cessation intervention did not adversely impact alcohol, other drug, or tobacco use outcomes, and demonstrated success for a small portion of these veterans.

      Declaration of Interest

      The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. The contents of this publication do not represent the views of the Department of Veterans Affairs or the United States Government.

      Acknowledgment

      The authors would like to thank the Salem, Virginia Veterans Affairs Medical Center SARRTP treatment team for their support throughout this research.

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