Low rates of recommended treatment for tobacco dependence in patients hospitalized with SUDs

Reviewed by James Ives, M.Psych. (Editor)Jun 24 2019

Tobacco dependence is very common in patients hospitalized with substance use disorders (SUDs) – but most don't receive recommended treatment for tobacco dependence while in the hospital, reports a study in the Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM). The journal is published in the Lippincott portfolio by Wolters Kluwer.

"Inpatient addiction consultations represent a missed opportunity to counsel patients with SUDs to quit smoking," according to the new research by Hasmeena Kathuria, MD, of Boston University School of Medicine and colleagues. Their report includes suggestions from both patients and physicians on tobacco treatment strategies for this vulnerable group of patients.

Targeting smoking in inpatient care for SUDs

The researchers analyzed records from nearly 700 patients with SUDs admitted to the Addiction Consult Service (ACS) at a large safety-net hospital. For most patients, SUD included heroin, often along with cocaine and/or alcohol.

Records were reviewed to identify whether the patients received treatment for tobacco dependence. The analysis focused on the recommended "5 A's"of tobacco treatment: Ask about tobacco use, Advise smokers to quit, Assess whether the person is willing to try quitting, Assist them in their attempt, and Arrange follow-up care.

Most patients with SUD were asked about tobacco use, and 75.5 percent were smokers. By comparison, about 18 percent of patients without SUD at the same hospital were current smokers.

However, only a minority of patients with SUD who smoked received any of the other recommended treatment steps. About 22 percent received "assistance" treatment steps – most often consisting of nicotine patches, intended to ease nicotine withdrawal symptoms during the hospital stay. "Only 5.4 percent of hospitalized SUD smokers received the full 5 A's approach from the ACS team," Dr. Kathuria and colleagues write.

Why wasn't tobacco dependence addressed more often? Physicians said that they typically discuss tobacco treatment in the outpatient clinic, but several patients said that they don't make outpatient visits. "Many patients would welcome discussions on tobacco dependence while hospitalized," the researchers write.

The addiction medicine physicians identified several barriers to tobacco treatment in the hospital. The doctors perceived that treating tobacco dependence in the hospital "is not a priority" for SUD patients, who would find it difficult to "quit all substances at once."

The ACS physicians also identified some factors that facilitated treatment, including linking smoking-cessation efforts to the success of SUD treatment. One physician suggested the message: "If you're able to quit smoking, it's a very positive prognostic sign for you to be able to do well on the rest of your addiction treatment."

Based on discussions with both patients and physicians, the authors outline a framework for in-hospital and follow-up treatment for tobacco dependence in SUD patients. Initial treatment can include nicotine replacement therapy or other pharmacotherapy such as varenicline to manage symptoms of tobacco withdrawal.

Smoking cessation counseling should be discussed in the hospital when the patient is stable from acute drug or alcohol withdrawal, and tobacco treatment should be continued during follow up treatment for SUD in the office and/or addiction treatment centers. Dr. Kathuria and colleagues add that to reduce disparities in smoking cessation outcomes in SUD patients, "System-level changes are needed to coordinate treatment of tobacco and other drug dependence in hospitalized smokers."