Overview of state policies requiring smoking cessation therapy in psychiatric hospitals and drug abuse treatment centers

Abstract

Background

Research demonstrates that individuals in substance abuse treatment are more likely to die from tobacco addiction than from their primary addiction, yet historically substance abuse treatment has not included treatment for tobacco addiction. The purpose of our study was to (1) review the diffusion of state policies mandating the provision of tobacco cessation treatment as a condition of state licensure in substance abuse treatment facilities and psychiatric treatment centers and (2) describe the current landscape of policies relating to tobacco cessation in state-licensed substance abuse treatment facilities and psychiatric treatment centers.

Findings

We conducted a nationwide assessment of all 50 states from May 2013 - October 2014 to determine the progress each has made with developing a statewide tobacco cessation policy. We reviewed state government websites, conducted phone interviews with state regulatory agencies, and emailed state employees. Overall, 13 of 50 states (26 %) require tobacco cessation provision in alcohol, drug rehabilitation, and or mental health treatment centers, 6 states (12 %) are currently working towards a state policy, and 31 states (62 %) do not require tobacco cessation nor are working towards a state policy, though many of them have smoke free policies in both substance abuse centers and mental health wards.

Conclusions

Our updated review of statewide smoking cessation policies in alcoholic, drug abuse, and mental health populations reveals that while clinical findings that affect population health may be well-publicized in the research community, these findings are not necessarily translated into policy. Further research on policy diffusion is needed.

Findings

Background

Patients undergoing treatment for mental health or substance abuse are disproportionately affected by smoking. Research demonstrates that individuals in substance abuse treatment are more likely to die from tobacco addiction than from their primary addiction, yet historically substance abuse treatment has not included treatment for tobacco addiction [1–3]. Among tobacco users receiving substance abuse treatment, the death rate from tobacco use was 1.5 times greater than from other addiction causes [1, 3].

Efforts to integrate simultaneous tobacco cessation therapy into chemical dependency and mental health treatment units have been hindered by several factors. Providers fear that quitting smoking simultaneously will compromise efforts to recover from other additions [4, 5], despite research showing that including tobacco cessation in addictions treatment does not compromise the treatment and sobriety of patients receiving simultaneous care for alcohol and drug abuse [6, 7]. Many healthcare providers also believe that the health risks from smoking are less important than the perceived benefits of smoking, which are thought to calm psychiatric patients and reduce the risk of relapse [Apollonio D, Philipps R, Bero L. 2012. "Interventions for tobacco cessation in people in treatment for or recovery from substance abuse." Cochrane Library v. 12, pp. 1–10]. Additional barriers include uncertainty regarding the best time to integrate smoking cessation treatment, and the fact that many individuals who staff drug abuse clinics and psychiatric wards are smokers themselves [Apollonio D, Philipps R, Bero L. 2012. "Interventions for tobacco cessation in people in treatment for or recovery from substance abuse." Cochrane Library v. 12, pp. 1–10].

Despite these challenges, some policymakers have started to recognize the need for concurrent treatment and have taken steps to shift the policy landscape in this area. In 2001, New Jersey implemented a policy that required substance abuse treatment centers to provide tobacco cessation treatment as a condition of licensure. In the first year, the state reported increases in tobacco abstinence among those in residential treatment, with no increase in irregular discharges. These findings were consistent with other literature suggesting concurrent treatment for tobacco and other substances is effective.

Recognizing this success, New York enacted its own tobacco cessation policy in 2008. In recent years, similar policies have been proposed in other states (Colorado, South Carolina, and Connecticut) but not enacted, and multiple institutions have chosen to offer smoking cessation therapy to clients on a voluntary basis. Nevertheless, there is no listing of current policies that address the issue, and no tracking of proposed policies.

The purpose of this study is two-fold: (1) to review the diffusion of state policies mandating the provision of tobacco cessation treatment as a condition of state licensure in substance abuse treatment facilities and psychiatric wards and (2) to describe the current landscape of policies relating to tobacco cessation in state-licensed substance abuse treatment facilities and psychiatric wards. We hypothesized that there may be increased reliance on research findings regarding tobacco cessation in the policymaking process, either directly or indirectly through the efforts of policy advocates and health care professionals, which would be demonstrated by the adoption of laws that provide greater protection against tobacco-related disease.

Methods

We reviewed the public commentary and background information on proposed and existing policies to assess how the use of clinical evidence in the policymaking process is associated with legislative and regulatory outcomes. We searched state government websites and conducted phone interviews and/or email exchanges with the representatives of state regulatory agencies (1–2 contacts per state, depending on each agency’s regulatory authority) to determine the progress each state has made in developing policies of this nature. All data were collected between May 2013 and February 2014. We updated the database in October 2014 to account for any changes in a state’s status.

Study population

Our goal was to assess state policies that address tobacco addiction in marginalized populations, which suffer the greatest burden of tobacco-related disease. For the purposes of this study, we define these populations as individuals in treatment for substance use or mental health disorders. We focused on statewide policies because they represent large-scale systemic change that can immediately affect these groups. Localities or individual treatment centers may choose to require or offer smoking cessation therapy to clients on a case-by-case basis, but these efforts have limited scope. Federal policy does not currently address tobacco cessation in substance use or mental health treatment facilities. Although facilities that are federally accredited would be subject to any new rulemaking on this issue, many treatment centers that serve marginalized populations are not federally accredited, yet are subject to state policy. As a result, state policies are most likely to affect tobacco use in these groups.

Types of interventions

We defined smoking cessation therapy to include at least one of the following interventions.

• Counseling only, both individual and group sessions, delivered in a clinic setting for tobacco cessation purposes during the course of existing addictions treatment, or in addition to existing interventions for other addictions

• Nicotine replacement therapy (NRT) of all modalities (e.g. gum, patch), both prescription and over-the-counter, offered to individuals for tobacco cessation purposes during the course of existing addictions treatment

• Non-NRT pharmacology (e.g. varenicline or bupropion) offered to individuals for tobacco cessation purposes during the course of existing addictions treatment

• A combination of any of the above methods

Analysis

States were categorized as (a) requiring tobacco cessation provision in alcohol, drug rehabilitation and/or mental health treatment centers, (b) working towards a state policy, or (c) no state regulation or policy proposals.

Results

As shown in Table 1, 13 of 50 states (26 %) require tobacco cessation provision in alcohol, drug rehabilitation, and or mental health treatment centers. Among the states mandating the provision of tobacco cessation services, five states require tobacco cessation only in substance use treatment centers, five states require tobacco cessation in both substance use treatment centers and mental health treatment centers, two states require cessation only in mental health treatment centers, and one state did not distinguish whether tobacco cessation is required in substance use treatment centers, mental health treatment centers, or both.

Table 1 Current regulations in states requiring tobacco cessation provision (n = 13/50, 26 %)

Table 2 shows that six states (12 %) are currently working towards a state policy. Among the states working towards a state policy, three states have proposed tobacco cessation be required only in substance use treatment centers, two states proposed tobacco cessation be required in both substance use treatment centers and mental health treatment centers, and one state proposed tobacco cessation be required only in mental health treatment centers.

Table 2 Current regulations in states working toward a state policy (n = 6/50, 12 %)

The following 31 states (62 %) do not require tobacco cessation nor are working towards a state policy, though many of them have smoke free policies in both substance abuse centers and mental health wards: Connecticut, Ohio, Michigan, Wisconsin, Kentucky, Tennessee, Pennsylvania, South Carolina, Georgia, West Virginia, Mississippi, Nebraska, South Dakota, North Dakota, Arizona, California, Nevada, Alaska, Missouri, Wyoming, Kansas, Rhode Island, Florida, Idaho, Delaware, Virginia, Utah, Hawaii, Illinois, Indiana, and Minnesota. Table 3 lists steps these states have taken, without proposing or enacting statewide policies, to address smoking and smoking cessation in substance abuse centers and/or psychiatric wards.

Table 3 Current regulations in states not working toward a state policy (n = 31/50, 62 %)

Conclusion

Although we hypothesized that an increase in reliance on clinical research findings in the policymaking process could lead to the widespread adoption of state policy to protect against tobacco related disease, our exploratory analysis revealed this has not happened. Only one western state (Oregon) has enacted a statewide policy; suggesting that any policy diffusion has primarily occurred on the East Coast. Furthermore, most existing statewide regulations affect only substance use treatment centers and do not apply to mental health treatment centers.

In 2011, the National Survey of Substance Abuse Treatment Services (N-SSATS) published statewide data showing the percentage of substance abuse treatment facilities that provided tobacco cessation services, including tobacco cessation counseling, nicotine replacement therapy, and/or non-nicotine tobacco cessation medication [8]. The geographic differences presented in that survey are consistent with our finding that substance abuse centers offering tobacco cessation therapy were more likely to be located in the US Northeast than centers that did not offer these services. In New York, 83 % of substance abuse centers offered tobacco cessation services, giving it the highest percentage of any state to offer such services. Given that New York enacted a regulation requiring the provision of tobacco cessation as a condition of licensure for the state’s substance use treatment facilities in 2008, enforcement was not consistent as of 2011. Similarly, Texas enacted a state policy in 2010, yet only 44 % of its substance abuse centers were providing tobacco cessation in 2011. These examples raise concern about the extent to which statewide tobacco cessation policies that pass are enforced.

Overall, our updated description of statewide smoking cessation policies in alcohol, drug abuse, and mental health populations suggests that despite the well-publicized early success of the New Jersey policy, the overall diffusion of similar policies has been slow. A recent systematic review found that the continuing limited provision of tobacco cessation therapy in drug abuse and mental health treatment is not due to lack of knowledge about its positive effects [9]. States, however, have been slow to enact formal policies since New Jersey’s initiation in 2001, and New Jersey weakened its own policy several years later. The failure to enact or retain these policies may reflect limited resources, a lack of awareness of policies in other states, hostility from service providers who view tobacco cessation as a low priority, or a decision to “watch and wait” for the results of other states’ policies. In additional, even in states that do enact such policies, enforcement may be inconsistent across states and over time. Further study investigating what factors may prevent state policymakers from developing and implementing policies in this area is warranted.

Study limitations

When reporting results we do not distinguish what form (counseling, nicotine replacement therapy, non-NRT pharmacology, etc.) of tobacco cessation therapy is required from each state, so are unable to compare which treatment is most common. We were unable to find this information via our search of state government websites and interviews with state regulatory agencies and employees.