摘要：Objectives. We used admissions data from the New York State addiction treatment system to assess patient self-reported tobacco use and factors associated with tobacco use. Methods. We compared prevalence of tobacco use in the state addiction treatment system with that of a national sample of people receiving addiction treatment and with that of the New York general population in 2005 to 2008. A random effects logistic model assessed relationships between patient- and program-level variables and tobacco use. Results. Prevalence of tobacco use in the New York treatment system was similar to that in national addiction treatment data and was 3 to 4 times higher than that in the general population. Co-occurring mental illness, opiate use, methadone treatment, and being a child of a substance-abusing parent were associated with higher rates of tobacco use. Conclusions. We call on federal leadership to build capacity to address tobacco use in addiction treatment, and we call on state leadership to implement tobacco-free grounds policies in addiction treatment systems. Since the 1964 Surgeon General’s report, 1 public health and policy efforts have decreased smoking prevalence in the United States from 40% to 18%. 2,3 The decrease in smoking since 2005 has been slight, 4 however, and smoking is now concentrated in subgroups defined by demographics, 5 diagnosis, 6 or behavior. 7–9 Behavioral health populations, especially, have not benefited from the overall population decline in smoking prevalence. 10 People with mental health diagnoses are twice as likely to smoke as those without, 11 and the highest prevalence rates reported are among people who seek treatment for alcohol or drug addiction. National Survey on Drug Use and Health (NSDUH) data show that, among people who reported past-year addiction treatment, annual smoking prevalence for 2000 to 2009 ranged from 67% to 75%. 12 Four million people receive addiction treatment annually, and 2.3 million receive services in specialty addiction programs. 13 If 70% are smokers, 12 then 1.6 million smokers enter such programs annually. Year after year, these settings serve a substantive proportion of the 43.8 million US adult smokers. 5 Despite high rates of tobacco use, only 1 in 5 addiction treatment facilities in the United States has the financial resources to provide tobacco cessation services. 14 Availability of nicotine replacement therapy in addiction programs decreased over 4 years (from 38% to 34%), 15 and 40% of programs providing cessation counseling in 2006 to 2008 later discontinued this service. 16 According to the 2011 National Survey of Substance Abuse Treatment Services (N-SSATS), only half of all addiction treatment programs screen clients for tobacco use. 17 Three fourths of all addiction treatment is provided in the public sector, 18,19 and regulation and policy setting for these programs are centralized in Single State Agencies for Substance Abuse Services. Such agencies could disseminate tobacco practice guidelines, mandate counselor education on tobacco dependence, 20 or reimburse programs for tobacco-related services. 21 Several state addiction treatment systems have initiated or contemplated tobacco control efforts. 22–24 In July 2008, the New York Office of Alcoholism and Substance Abuse Services (OASAS) mandated smoke-free grounds and treatment of tobacco dependence for patients in addiction treatment. 25 The largest such policy in the United States, it affects approximately 1000 programs, 20 000 staff, and 300 000 annual treatment admissions. Interviewing program administrators before and after the regulation, Brown et al. 26 found increased tobacco screening and cessation services for patients. Surveying patients before and after the policy, another study found that smoking prevalence decreased from 69% to 63% ( P < .05) and that tobacco-related services increased in methadone treatment settings but decreased in residential treatment. 27 Studies assessing clinicians’ perspectives on implementation of the OASAS tobacco regulation identified both positive experiences (e.g., increased patient awareness about tobacco abuse) and negative experiences (e.g., enforcement difficulties), 28 coupled with perceived increases in program-level commitment of resources and enforcement efforts over time. 29,30 Before implementing its tobacco control policy, OASAS included tobacco use status in the patient admission record. The resulting data set permits assessment of the relationships between tobacco use and other factors in statewide addiction treatment samples. By comparison, a review of 42 addiction treatment studies reporting smoking prevalence included sample sizes ranging from 29 to 3472. 12 NSDUH epidemiological data have been used to assess smoking prevalence among people with mental illness, 31 people with concurrent alcohol and illicit drug misuse, 32 and people receiving addictions treatment in the past year. 12 We know of no studies using NSDUH or similar national data sets to explore factors associated with tobacco use in the addiction treatment population. Such data are of interest because tobacco policies in addictions treatment have potential to reduce tobacco use in a population in which use is highest, in which users are concentrated, and in which the burden of tobacco-related mortality is disproportionate. 33,34 We used admissions data from the New York State addiction treatment system (OASAS) over a 6-year period to estimate prevalence of tobacco use. Comparison with statewide data reflects how much people enrolled in the New York addiction treatment system may smoke in comparison with all New York State residents. Comparison with NSDUH data reflects how much people enrolled in the New York addiction treatment system may smoke in comparison with a national sample of people receiving addiction treatment. We also assessed how program and patient characteristics may be associated with tobacco use in this population.
