摘要：Objectives. We assessed changes in smoking prevalence and other measures associated with the July 2008 New York Office of Alcoholism and Substance Abuse Services tobacco policy, which required that all publicly funded addiction treatment programs implement smoke-free grounds, have “no evidence” of smoking among staff, and make tobacco dependence treatment available for all clients. Methods. In a random sample of 10 programs, staff and clients were surveyed before the policy and 1 year later. Measures included tobacco-related knowledge, attitudes, and practices used by counselors and received by clients. Results. Client smoking decreased from 69.4% to 62.8% ( P = .044). However, response to the policy differed by program type. Outpatient programs showed no significant changes on any of the staff and client survey measures. In methadone programs, staff use of tobacco-related practices increased ( P < .01), client attitudes toward tobacco treatment grew more positive ( P < .05), and clients received more tobacco-related services ( P < .05). Residential clients were more likely to report having quit smoking after policy implementation (odds ratio = 4.7; 95% confidence interval = 1.53, 14.19), but they reported less favorable attitudes toward tobacco treatment ( P < .001) and received fewer tobacco-related services from their program ( P < .001) or their counselor ( P < .001). Conclusions. If supported by additional research, the New York policy may offer a model that addiction treatment systems can use to address smoking in a population where it has been prevalent and intractable. Additional intervention or policy supports may be needed in residential programs, which face greater challenges to implementing tobacco-free grounds. Persons with substance abuse and dependence smoke at higher rates 1–3 and smoke more heavily 4,5 than do persons in the general population. They may be more physically dependent on nicotine, 6 less successful in quit attempts, 7 and may die from smoking-related causes more frequently than from drug- or alcohol-related causes. 8 For 30 years, research has noted the high rate of smoking among persons with other addictive disorders 9–12 and several authors have argued that addiction treatment programs should address tobacco. 13–16 Although this is reflected in clinical guidelines 17 and policy statements, 18,19 several studies have found that tobacco dependence is often not addressed in addiction treatment. 20–22 Treatment of tobacco dependence in addiction settings may be accelerating. 23 Veteran Affairs Medical Centers implemented smoking cessation practice guidelines for all patients, including those in addiction clinics, 24 and New Jersey required tobacco-free grounds for residential drug treatment. 25 Following the New Jersey initiative, all programs provided more tobacco-related treatment, half adopted smoke-free grounds, and 41% of smokers did not smoke during their residential stay. 25 In 2008, the New York Office of Alcoholism and Substance Abuse Services (OASAS) required all state-certified addiction treatment programs to implement tobacco-free grounds, to have no-evidence (of smoking) policies for staff, and to provide tobacco dependence intervention for clients on request. 26 Tobacco-free grounds means no smoking anywhere on program grounds, including outdoor areas. No evidence of smoking means staff do not come to work smelling of tobacco smoke, or have cigarettes or other tobacco products or paraphernalia in view in the work area. Tobacco dependence intervention means smoking cessation counseling and nicotine replacement therapy (NRT). Tobacco dependence services are free to clients, with costs bundled into program contracts with the state. The policy affects 1550 programs, 20 000 staff, and 250 000 annual admissions. To support the policy, the state committed $4 million to deliver staff training and $4 million to provide NRT to treatment programs. The OASAS Web site listed volunteer mentors to help programs implement the policy, and offered online tobacco dependence training for counselors. Program licensing visits included review and grading on policy compliance. We report findings from staff and client surveys conducted in a random sample of programs before and after the policy was implemented.
