NIHR Signal Stop smoking services can work for people in treatment or recovery from substance misuse disorders
Published on 8 August 2017
Providing stop smoking services to people with substance misuse disorders increases the numbers of people who stop smoking by about 10% without reducing the rates of abstinence from drugs or alcohol. Combined drug treatment and counselling showed the best result though pharmacotherapy alone was also successful. However counselling alone was not beneficial.
This Cochrane review included trials of people who were already either in treatment or recovery for drug or alcohol misuse in a variety of settings. Those in the treatment groups were given counselling, pharmacotherapy, or a combination of both to reduce smoking, and compared to usual care or placebo. The type of substance misuse disorder was not related to success rates.
Smoking rates amongst people dependent on alcohol or drugs are high. Treatment to also reduce smoking in this group is rare as it has been thought that adding stopping smoking treatments will reduce the effectiveness of substance misuse treatments. This is not the case, and offering help to stop smoking can be safely provided.
- Medicines, Mental health and illness, Public Health, Substance misuse
Why was this study needed?
Smoking rates amongst people with substance misuse disorders are two to four times higher than the general population, and half of all smoking-related deaths are thought to come from this group. Smoking rates in this group have remained constant while rates in the general population have steadily declined.
There have been concerns that suggesting people stop smoking at the same time as dealing with alcohol or substance misuse might jeopardise their recovery. This review aimed to see if this is the case and which interventions worked best.
What did this study do?
This was a systematic review and meta-analysis that included 34 randomised controlled trials. It looked at interventions to reduce smoking in people in treatment or recovery from substance misuse to determine its effects on both smoking reduction and substance abstinence. Studies were included if the intervention was pharmacotherapy or counselling, or a combination of the two. Together, the studies involved 5,796 participants from the US, Brazil, Iran, Switzerland, and Spain. The majority of the studies were American and the counselling varied in its duration and intensity.
Studies were analysed by intervention type, whether participants were in treatment or recovery, and by type of dependency (alcohol or drugs). The length of maximum follow-up ranged from six to 18 months.
The risk of bias in many of the included studies was unclear due to incomplete reporting thus the overall quality of studies is low. Publication bias could have explained some the apparent effect of medication.
What did it find?
- Smoking cessation treatments did not reduce abstinence from substance misuse (relative risk [RR] 0.97, 95% confidence interval [CI] 0.91 to 1.03).
- Combined pharmacotherapy and counselling was the best smoking cessation treatment, with about 16% quitting compared to 9% with usual care at 13 weeks to 18 months (RR 1.74, 95% CI 1.39 to 2.18) 12 trials, 229 participants.
- Pharmacotherapy alone was also effective, with about 13% quitting compared to 8% at eight weeks to six months (RR 1.60, 95% CI 1.22 to 2.12) 11 trials, 1808 participants. When types of medication were analysed separately, nicotine replacement was effective whereas non-nicotine therapies were not.
- Counselling alone was similar to usual care at six weeks to 12 months (RR 1.33, 95% CI 0.90 to 1.95) 11 trials, 1759 participants.
- At 18-months people quit if they were either in treatment (RR 1.99, 95% CI 1.59 to 2.50) or in recovery (RR 1.33, 95% CI 1.06 to 1.67).
What does current guidance say on this issue?
The 2013 NICE Public Health Guideline recommends that all healthcare workers encourage people to stop smoking. This includes people who are seen within drug and alcohol services. They recommend developing a personal stop smoking plan with intensive behavioural support and pharmacotherapy. A combination of the following pharmacotherapy options is advised according to individual preferences: nicotine patches, an inhalator, gum, lozenges or spray.
What are the implications?
The review indicates that providing smoking cessation services to this group has positive effects on smoking reduction while not affecting abstinence rates from other substance dependency. The evidence for not affecting drug or alcohol withdrawal is reliable but nicotine replacement therapy may be somewhat less effective than this analysis suggests and counselling slightly more effective in a well-organised quitting service.
NICE guidance already recommends providing Stop Smoking Services to disadvantaged groups and people using mental health services. However, they were aware that the evidence of their effectiveness was lacking. This review provides evidence that it is effective for this sub-population. The interventions reviewed are interventions already in place in the NHS and this evidence suggests that quit-rates of about 10% could be achievable in this under-treated group.
Citation and Funding
Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders. Cochrane Database Syst Rev. 2016;(11):CD010274.
This review was supported by National Cancer Institute grant CA-140236 and the University of California, San Francisco (UCSF) Research Allocation Program.
NICE. Smoking: acute, maternity and mental health services. PH48. London: National Institute for Health and Care Excellence; 2013.
NICE. Stop smoking services. PH10. London: National Institute for Health and Care Excellence; 2008.
NICE. Smoking: brief interventions and referrals. PH1. London: National Institute for Health and Care Excellence; 2006.
Should smokers, who also have alcohol or other drug addictions, be denied simultaneous treatments to help them stop smoking? Such patients are often at a higher risk of death from smoking. Yet it is not uncommon for these patients to be denied smoking cessation treatments, while also being treated for these other addictions. This may be attributed to uncertainty in the benefits of treating these different addictions at the same time.
However, the findings from this Cochrane review suggests that there is no reason why smokers, being treated for, or recovering from other addictions, be denied simultaneous support to help them stop smoking.
Dr Kamal R. Mahtani, GP & Deputy Director of the Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford
Secondary care refers to care secondary and tertiary care facilities such as drug and alcohol services, inpatient, residential and long-term care services, and other specialist units.