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.

Stop smoking services can work for people in treatment or recovery from substance misuse disorders

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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).

Stop smoking interventions for people undergoing treatment for substance use disorders

 

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.

Bibliography

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.

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).

Stop smoking interventions for people undergoing treatment for substance use disorders

 

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.

Bibliography

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.

Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders

Published on 24 November 2016

Apollonio, D.,Philipps, R.,Bero, L.

Cochrane Database Syst Rev Volume 11 , 2016

BACKGROUND: Smoking rates in people with alcohol and other drug dependencies are two to four times those of the general population. Concurrent treatment of tobacco dependence has been limited due to concern that these interventions are not successful in this population or that recovery from other addictions could be compromised if tobacco cessation was combined with other drug dependency treatment. OBJECTIVES: To evaluate whether interventions for tobacco cessation are associated with tobacco abstinence for people in concurrent treatment for or in recovery from alcohol and other drug dependence. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and clinicaltrials.gov databases, with the most recent search completed in August 2016. A grey literature search of conference abstracts from the Society on Nicotine Research and Treatment and the ProQuest database of digital dissertations yielded one additional study, which was excluded. SELECTION CRITERIA: We included randomised controlled trials assessing tobacco cessation interventions among people in concurrent treatment for alcohol or other drug dependence or in outpatient recovery programmes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study risk of bias and extracted data. We resolved disagreements by consensus. The primary outcome was abstinence from tobacco use at the longest period of follow-up, and the secondary outcome was abstinence from alcohol or other drugs, or both. We reported the strictest definition of abstinence. We summarised effects as risk ratios and 95% confidence intervals (CI). Two clustered studies did not provide intraclass correlation coefficients, and were excluded from the sensitivity analysis. We used the I2 statistic to assess heterogeneity. MAIN RESULTS: Thirty-five randomised controlled trials, one ongoing, involving 5796 participants met the criteria for inclusion in this review. Included studies assessed the efficacy of tobacco cessation interventions, including counselling, and pharmacotherapy consisting of nicotine replacement therapy (NRT) or non-NRT, or the two combined, in both inpatient and outpatient settings for participants in treatment and in recovery. Most studies did not report information to assess the risk of allocation, selection, and attrition bias, and were classified as unclear.Analyses considered the nature of the intervention, whether participants were in treatment or recovery and the type of dependency. Of the 34 studies included in the meta-analysis, 11 assessed counselling, 11 assessed pharmacotherapy, and 12 assessed counselling in combination with pharmacotherapy, compared to usual care or no intervention. Tobacco cessation interventions were significantly associated with tobacco abstinence for two types of interventions. Pharmacotherapy appeared to increase tobacco abstinence (RR 1.60, 95% CI 1.22 to 2.12, 11 studies, 1808 participants, low quality evidence), as did combined counselling and pharmacotherapy (RR 1.74, 95% CI 1.39 to 2.18, 12 studies, 2229 participants, low quality evidence) at the period of longest follow-up, which ranged from six weeks to 18 months. There was moderate evidence of heterogeneity (I2 = 56% with pharmacotherapy and 43% with counselling plus pharmacotherapy). Counselling interventions did not significantly increase tobacco abstinence (RR 1.33, 95% CI 0.90 to 1.95).Interventions were significantly associated with tobacco abstinence for both people in treatment (RR 1.99, 95% CI 1.59 to 2.50) and people in recovery (RR 1.33, 95% CI 1.06 to 1.67), and for people with alcohol dependence (RR 1.47, 95% CI 1.20 to 1.81) and people with other drug dependencies (RR 1.85, 95% CI 1.43 to 2.40).Offering tobacco cessation therapy to people in treatment or recovery for other drug dependence was not associated with a difference in abstinence rates from alcohol and other drugs (RR 0.97, 95% CI 0.91 to 1.03, 11 studies, 2231 participants, moderate evidence of heterogeneity (I2 = 66%)).Data on adverse effect of the interventions were limited. AUTHORS' CONCLUSIONS: The studies included in this review suggest that providing tobacco cessation interventions targeted to smokers in treatment and recovery for alcohol and other drug dependencies increases tobacco abstinence. There was no evidence that providing interventions for tobacco cessation affected abstinence from alcohol and other drugs. The association between tobacco cessation interventions and tobacco abstinence was consistent for both pharmacotherapy and combined counselling and pharmacotherapy, for participants both in treatment and in recovery, and for people with alcohol dependency or other drug dependency. The evidence for the interventions was low quality due primarily to incomplete reporting of the risks of bias and clinical heterogeneity in the nature of treatment. Certain results were sensitive to the length of follow-up or the type of pharmacotherapy, suggesting that further research is warranted regarding whether tobacco cessation interventions are associated with tobacco abstinence for people in recovery, and the outcomes associated with NRT versus non-NRT or combined pharmacotherapy. Overall, the results suggest that tobacco cessation interventions incorporating pharmacotherapy should be incorporated into clinical practice to reduce tobacco addiction among people in treatment for or recovery from alcohol and other drug dependence.

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.

Expert commentary

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

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  •   Medicines, Mental health and illness, Public Health