(2) Addressing the Whole Patient: Examination of Smoking Policies in SUD Treatment Facilities

Background & Introduction: Many individuals who present to treatment facilities for substance use disorders (SUDs), such as alcohol use disorder or stimulant use disorder, have a concomitant tobacco use disorder (TUD). Despite the high rates of smoking among those with a SUD and the increase in morbidity and mortality associated with tobacco use, not all SUD treatment facilities address the treatment of comorbid TUD or restrict tobacco use on campus. Misconceptions exist that placing an emphasis on smoking cessation during addiction treatment jeopardizes treatment retention and success. However, studies have shown that smoking cessation has no negative effect on the treatment of concomitant SUDs and may, in fact, aid in beneficial treatment outcomes. Furthermore, given that smoking is associated with a return to previous patterns of substance use, treatment for TUD is even more relevant for individuals who smoke and receive SUD treatment. The aims of this research were to 1) describe tobacco-related treatment options and smoking policies in SUD treatment facilities, and 2) examine how state-level and organizational-level factors are related to SUD facility smoking policies.

Methods: This study examined SUD facility smoking policies in a national sample of N=16,623 SUD treatment providers in the United States in 2021. Three data sources were used to examine state-level data associated with SUD facility smoking policies. These sources included 1) Behavioral Risk Factor Surveillance System (BRFSS) Prevalence & Trends Data: 2020, 2) National Substance Use and Mental Health Services Survey (N-SUMHSS), 2021, and 3) U.S. State Laws Requiring Tobacco-Free Grounds for Mental Health and Substance Use Facilities. Descriptive statistics were used to separately examine the (1) N=13,778 SUD facilities with outpatient treatment and (2) N=3,449 SUD facilities with non-hospital residential treatment. Multinomial logistic regression analyses were conducted to quantify the relationships between independent variables and permissiveness of facility smoking policies. Independent variables included (1) Binary State Proportion of Adults who use Tobacco, (2) State Laws Requiring Tobacco-Free Grounds, (3) Assessment Screening or Education/Counseling for Tobacco, and (4) Pharmacotherapy: Nicotine Replacement or Non-Nicotine Cessation. Smoking policies were classified as most permissive (Permitted Anywhere Outside, Designated Indoor Area(s), Anywhere Inside, or Anywhere), semi-permissive (Permitted in Designated Outdoor Area(s)), and least permissive (Not Permitted to Smoke Anywhere Outside or Within Any Building).

Results: The states with the lowest and highest proportions of adults who used tobacco in 2020 were Utah (8.2%) and West Virginia (22.6%), respectively. Nine states had a state law requiring tobacco-free grounds for SUD treatment facilities. These nine states are: Alaska, Hawaii, Illinois, Indiana, Maine, New Mexico, New York, North Dakota, and Oregon. Most outpatient SUD facilities (58.4%) and residential SUD facilities (65.2%) were located in the 25 states (and DC) with the lowest proportion of adults who use tobacco. Most facilities with outpatient treatment (52.1%) and facilities with residential treatment (67.8%) had a smoking policy that permitted smoking in designated outdoor area(s). A multinomial logistic regression model found that among facilities with outpatient treatment (n=13,778), those located in a state with laws requiring tobacco free grounds at SUD facilities, those with tobacco screening/education/counseling services, and those with nicotine pharmacotherapy were less likely to have a permissive tobacco smoking policy. Among facilities with residential treatment (n=3,449), those with tobacco screening/education/counseling services were less likely to have the most permissive smoking policy than the least permissive smoking policy (AOR = 0.240, 95% CI = 0.130, 0.444, p<.001). Additionally, facilities in states with laws requiring tobacco-free grounds for SUD facilities were less likely to have a semi permissive smoking policy than the least permissive smoking policy (AOR = 0.310, 95% CI = 0.259, 0.370, p<.001).

Conclusion & Discussion: People with substance use disorders have a significantly higher prevalence of smoking, indicating a disproportionate need for tobacco-related harm reduction. Restrictive SUD facility smoking policies may reduce tobacco-related disparities in this population. This study expands the literature by providing state and facility level factors associated with SUD facility smoking policies. State level analysis demonstrated variability in the percentage of facilities with “semi-permissive” versus “least permissive” policies. However, few implement the “most permissive” policy, suggesting consensus that unrestricted smoking detracts from the health of patients. For outpatient facilities, three variables had a strong effect on smoking policy. State law requiring tobacco free grounds, presence of tobacco outreach services, and available pharmacotherapy all decreased the odds of having permissive smoking policies. If these relationships are causal, these factors could be leveraged to encourage more restrictive smoking policies. For residential facilities, fewer statistically significant relationships existed. This could mean that the relationship between these factors (e.g., state law), and smoking policies in a residential setting is weaker, or this could be due to smaller sample size. Study limitations include grouping of individual variables in the multivariable analyses due to small cell sizes and ignoring effects of vaping policies in SUD treatment facilities.

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