Tobacco Use Among Drug Dependent Patients in Treatment Setting

Original Article Tobacco Use Among Drug Dependent Patients in Treatment Setting Sonali Jhanjee,* Yatan Pal Balhara,** Hem Sethi** *Department of Psychiatry, All India Institute of Medical Sciences, New Delhi-110029 **National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi-110029 ABSTRACT Tobacco use is widely prevalent in substance using patients in treatment settings. Nearly three times as many individuals with alcohol and drug problems smoke cigarettes compared to the general population. In addition to addressing the primary drug of abuse, it is important to systematically assess characteristics and patterns of tobacco use and treat tobacco dependence in these patients as they are at high risk of mortality from tobacco related illnesses..consecutive patients presenting to the Tobacco Cessation Clinic of a national level deaddiction centre were assessed in detail using a semi-structured proforma. Most were males(97.3%) and majority (61.8%) of patients belonged to the 21-40 yrs age group. Most were self employed and primary drug of abuse was heroin in 47 (42.3%) and alcohol in 44 (39.6%) subjects. 53 (47.7%)used smoking tobacco only, 16 (14.7%) used only smokeless tobacco and 40 (36%) used a combination of both. Majority of smokable tobacco use was in the form of bidi (69.4%). Majority of the subjects (56.7%) were in the contemplation stage of change whereas 36 (32.7%) of subjects had taken steps towards quitting the use of tobacco products and qualified for the action stage as per RTCQ. The majority of patients qualified for moderate [56 (50.9%) dependence] to high dependence [37 (33.3%)] as per FTND score. This has obvious treatment implications. Key words: Smoking; Nicotine; Substance abusers; Treatment. Introduction Tobacco use is a global pandemic and has been recognized as the single most important source of preventable morbidity and premature mortality in the world. It is well documented that smoking substantially increases the risk of cancer, chronic obstructive pulmonary disease, coronary heart disease and many other medical problems. Cigarette smoking rates among the general adult population are reported to be in the range of 25-30% 1. The problem of smoking becomes acute in substance use disorder treatment settings where most individuals with alcohol and drug use disorders are also dependent on nicotine. Rates of nicotine use among abusers of illicit substances and alcohol are reported in the range of 85-100%. 2,3,4 Hence nearly three times as many individuals with alcohol and drug problems smoke cigarettes compared to the general population. Additionally, 40 50% of these patients are heavy smokers i.e. more than 25 cigarettes per day. 5 Smoking with other drug use contributes to the alarmingly high rates of morbidity and mortality in this population. According to data, for every death from opium, cocaine or their derivatives, there are almost 20 attributable to alcohol use and 80 attributable to cigarette smoking (1:20:80). 6 Likewise, Hser and colleagues 7 in their 24-year follow-up of drug users the death rates of smokers were four times that of non-smoker. Continued cigarette smoking has also been linked to worse substance abuse treatment outcomes 8 Despite the scope of this problem, tobacco use is largely ignored or delayed in addiction- treatment settings. Because the focus of Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 247

DELHI PSYCHIATRY JOURNAL Vol. 12 No.2 OCTOBER 2009 treatment is usually the primary drug of abuse like opioids and alcohol, in these settings, smoking cessation may not be considered high priority. However, in recent years greater awareness of this issue has prompted new initiatives in substance abuse programs to specifically address the problem of smoking. However there is a relative lack of large scale published studies on tobacco use patterns of drug dependent patients seeking treatment. This study documents the pattern of tobacco use, severity of dependence and motivation to quit in patients presenting for treatment in a National level de- addiction centre with a view to systematically intervene and treat tobacco dependence in this population. Methodology The patients presenting to the Tobacco Cessation Clinic of the centre were assessed in detail using a semi-structured proforma. The patient population mainly consists of opioid and alcohol dependent patients, with nicotine as the secondary drug of abuse. This semi structured proforma included assessment of socio-demographic profile, the assessment of the substance use and the tobacco use proforma. The tobacco use proforma assessed type of tobacco product being used (smoking and smokeless), age of onset of the tobacco products, the duration of use, severity of tobacco dependence, complications due to tobacco use, the past attempts at quitting, readiness to quit tobacco products, treatment history and perceived self efficacy of the patients regarding their ability to control tobacco use in various real life situations. The severity of dependence is assessed using the Fagerstrom Test of Nicotine Dependence (FTND). 9 The Fagerström Test for Nicotine Dependence is a standard instrument and a composite measure of nicotine dependence. Studies have shown that the FTND had good test-retest reliability, convergent validity, and discriminant validity. 10 The higher the Fagerström score, the more intense is the patient s physical dependence on nicotine. Higher scores indicate that treatment of withdrawal symptoms, usually with nicotine replacement therapy, will be an important factor in the patient s plan of care. The motivation of the patients for quitting the tobacco products is assessed using the Readiness to Change Questionnaire (RCQ). 11 The RTCQ is a 12-item questionnaire, based on Prochaska and DiClemente s stages of change model, for assignment to Precontemplation, Contemplation, and Action stages. Precontemplation stage: not thinking about stopping smoking Contemplation: express ambivalence about stopping smoking Action: Has reduced or stopped In the original study the internal consistency and reliability of the scale was found to be satisfactory. 12 Results The total number of new cases seen were 111 (N=111). Socio-demographic profile: The majority of the patients seen at the clinic were males [108 (97.3%)]. The mean age of the patients was 36.2 ± 11.2 years. Most of the patients belonged to the age group 31-40 years (33%). 6 (5.4%) of the patients were less than 20 years old, 32 (28.8%) were in the age range 21-30 years, 24 (21.6%) were in the age range 41-50 years, 9 (8.1%) were 51-60 years old and 3 (2.7%) were more than 60 years old. 95 (86%) of the subjects were married and rest 16 (14%) were unmarried. The majority of the patients [28 (25.2%)] were educated up to the middle school. 18 (16.1%) of the patients were illiterate, 7 (7.8%) were able to read and write their name, 18 (16.0%) had primary education, 27 (24.8%) were educated up to class 10th or 12th, 8 (7.4%) were graduate and 3 (2.5%) possessed a post graduate degree or some technical qualification. 46 (41.6%) of the patients were self employed, 2 (1.4%) were students, 1 (0.1%) was house wife. 7 (6.2%) of the patients were never employed, 25 (22.8%) were presently unemployed, 18 (16.7%) were full time employed and 11 (9.6%) were part time employed. Substance use profile: All the 111 patients qualified for the diagnosis of tobacco dependence syndrome. Additionally, of the 111 subjects 47 (42.3%) used heroin in a dependent pattern, 44 (39.6%) used alcohol in dependent pattern, 13 (11.8%) were cannabis users, 11 (9.9%) used injection drugs, 7 (6%) were opium 248 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society

users and 4 (3.6%) used other opiates. Tobacco use profile: Of all the users the majority [53 (47.7%)] used smoking tobacco only, 16 (14.7%) used only the smokeless tobacco and 40 (36%) used a combination of both. Of all the users 27 (24.3%) were users of cigarette, 77 (69.4%) were users of bidi, 33 (29.7%) were gutkha users, 3 (2.7%) were paan users and 21 (18.9%) used khaini. The mean age of onset for tobacco use via smoking was 17 years and later for smokeless tobacco products ranging from 21-24 years. FTND scores: All the 111 patients qualified for the criteria for tobacco dependence. The patients were rated using the Fagerstrom Test of Nicotine Dependence (FTND). 18 (15.8%) of the patients qualified for the low dependence for nicotine on FTND scale. The majority 56 (50.9%) qualified for moderate dependence and 37 (33.3%) were having high dependence as per FTND score. Readiness to Change Questionnaire (RCQ): The motivation of the patients for quitting the tobacco products is assessed using the Readiness to Change Questionnaire (RCQ). 9 Based on the stages of change theory this instrument assesses the motivation of individual and can be used to categories the stage the individual is in the process of change. The subject can qualify for one of the three stages namely the pre-contemplation stage, contemplation stage and the action stage. Majority of the subjects (56.7%) were in the contemplation stage of change. 12 (10.6%) have not contemplated leaving use of tobacco products whereas 36 (32.7%) of subjects had taken steps towards quitting the use of tobacco products and qualified for the action stage as per RCQ. Discussion The present study brings out the profile of the patients presenting to the tobacco cessation clinic being run at a de- addiction center. Total number of new cases seen were 111 (N=111). The majority of the patients seen at the clinic were males [108 (97.3%)]. The mean age of the patients was 36.2± 11.2 years, with majority of the patients being in the age group 31-40 years (33%)]. 25 (22.8%) were presently unemployed and 18 (16.1%) of the patients were illiterate This is in keeping with the DAMS data from treatment centres in India where subjects were overwhelmingly male(97.2%) and about 33% of patients were between 21-30 years and 37% were between 31-40 years. A small number of the sample in the DAMS were unemployed(19.8%) and about 16% were illiterate. All the 111 patients in the present study qualified for the diagnosis of tobacco dependence syndrome. Heroin and alcohol were the substances being used by the majority of the patients with use of heroin reported by 42.3% and use of alcohol reported by 39.6%. Additionally, 6% of the patients used opium and another 3.6% used other opiates. The use of both these substances was in dependent pattern. This is in keeping with the data from the treatment centers in India where the surveys have found opioids and alcohol being the commonest substances reported by the treatment seekers. Drug Abuse Monitoring System (DAMS) conducted in 2004 13 puts the report of alcohol use by 43.9% of the treatment seekers and opiates as a group by use by 26%. 10 Heroin use was reported by 11.1% of the subjects in the DAMS study.. Smoking was the commonest form of the tobacco use, being used by 47.7% of the patients. Another 36% used the smoking form of tobacco along with smokeless form. 14.7% of the subjects used only the smokeless tobacco. Bidi was the commonest tobacco product being used as reported by 69.4%. Cigarette use was reported by 24.3%. Of the smokeless tobacco products 29.7% were gutkha users, 18.9% used khaini and 2.7% were paan users. The western literature suggests that smoking form is the commonest form of tobacco use In India, the availability of different forms of tobacco and its products available in the country reflect wide regional differences in the prevalence of oral and smokable tobacco rate.in the task force project, 14 among males 69% in Lucknow to 88% in Delhi reported tobacco smoking. Oral use was reported by 11.7% in Delhi to 31% in Lucknow. In this study, the mean age of onset for tobacco use via smoking was 17 years and later for smokeless tobacco products ranging from 21-24 years. Although there is very little documentary evidence from the studies in India, it is observed that tobacco use usually begins in adolescence. The Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 249

DELHI PSYCHIATRY JOURNAL Vol. 12 No.2 OCTOBER 2009 data from university students 15 showed that recruitment to tobacco was maximum between the age range 14-19 years. In the task force project 14 although different categories were used, high rates of initiation (74-87%) were reported in the age group 15-24 years. Using the Fagerstrom Test of Nicotine Dependence (FTND), the dependence of the patients was quantified. The majority of the patients here were either moderately (50.9%) or heavily (33.3%) dependent on the tobacco products they were being used. This would suggest that the patients presenting to the de- addiction centre have a high degree of dependence on tobacco. This is in keeping with literature as most substance abusers tend to be heavy smokers and are more nicotine dependent. 16, 17 Hence they are at a high risk of developing complications due to the use of tobacco products which would mean a high direct as well indirect cost to the individual, family and the community at large. From the therapist perspective this would mean a intensive multipronged intervention strategy for the management of tobacco dependence in this population. This would include the use of pharmacological as well as nonpharmacological interventions in this patient group. Multi-component interventions, which include nicotine replacement plus behavioral therapies, have generally had superior outcomes and are well suited for highly dependent smokers. 18 Shoptaw et al 19 also reported that there was a strong association between reductions in cigarette smoking and reductions in illicit substance use during treatment. Participants provided more opiate and cocaine-free urines during weeks when they met criteria for smoking abstinence than during weeks when they did not meet these criteria. Thus, treating nicotine dependence would have a better outcome for drug use disorders in general. The RTCQ findings in this study showed that 56.7% of the patients were in the contemplation stage of change. This would mean that these patients are thinking about quitting but express uncertainity about their desire or ability to stop. Several recent studies have found that clients in treatment for drug abuse are interested in quitting smoking 20-24 and that cigarette quit attempts do not cause relapse to illicit drug use. 25,26 The clinician s goal with the contemplator is to help him or her resolve ambivalence by upping the balance in favor of quitting by interventions such as psycho-education on the hazards of continuing with the use of tobacco, brief intervention, motivational interviewing and motivation enhancement sessions. All these interventions would aim at breaking the barriers and enhance treatment seeking. The rest 32.7% subjects were in the action stage of change and the intervention for this group of patients would aim at strengthening their efforts and medical help like nicotine replacement therapy in form of nicotine gum and mainly focus on relapse prevention sessions. Implications Tobacco use is widely prevalent in substance using patients in treatment settings. Further these patients are likely to be heavily nicotine dependent with associated treatment implications. Tobacco related illness is major cause of death for people who have undergone treatment for alcohol and illicit drug use. Thus the treating psychiatrist should clearly advise smoking cessation to all their drug and alcohol dependent patients. The proper management of the cases of substance use disorders would include a comprehensive management plan aimed at a detailed assessment of tobacco use, severity of dependence and stage of change appropriate intervention strategies. It cannot be over emphasized that until drug treatment facilities intervene treat their patients tobacco use, huge amounts of money will flow through the drug treatment system, overcome their primary drug of abuse, but die prematurely from tobacco-related illnesses. Hence growing scientific evidence argues for an integrated approach to treatment. References 1. US Department of Health and Human Services, The health consequences of smoking. Nicotine Addiction: A Report of the Surgeon General (DHHS Publication No.CDC 88-8406) Washington DC, US Government Printing Office 1988. 2. Bobo JK. Nicotine dependence and alcoholism epidemiology and treatment. J Psychoactive Drugs 1989; 21(3) : 323-329. 3. Burling TA, Ziff TC. Tobacco smoking: Acomparison between alcohol and drug 250 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society

abusing inpatients. Addict Behav 1988; 13,185-190. 4. Difranza JR, Guerrera MP. Alcoholism and smoking. J Studies Alcohol 1990; 51(2), 130-135. 5. Hughes J. Combining behavioral therapy and pharmacotherapy for smoking cessation. An update. In LS Onken, JD Blaine and JJ Boren (Eds.) Integrating Therapies with Medications in the Treatment of Drug Dependence (pp. 92-109). (NIDA Research Monograph 150). Bethesda MD: National Institutes of Health 1995. 6. American Lung Association. Smoking statistics pamphlet. New York:Smokefree Educational Services, Inc, 1992. 7. Hser YI, Anglin D, Powers K. A 24-year followup of California narcotics addicts. Arch Gen Psychiatry 1993; 50 : 577 584. 8. Frosch DL, Shoptaw S, Nahom D, Jarvik ME. Association between tobacco smoking and illicit drug use among methadone maintained opiate dependent individuals, Exp Clin Psychopharmacol 2000; 8 : 97-103. 9. Heatherton T, Kozlowski L, Frecker R, et al. The Faegerstorm s test for nicotine dependence: A revision of Faegerstorm s Toler ance Questionnaire. Br J Addict 1991; 86 : 1119-1127. 10. Buckley TC, Mozley SL, Holohan DR, Walsh K, Beckham JC, Kassel JD. A psychometric evaluation of the Fagerstrom Test for Nicotine Dependence in PTSD smokers. Addictive Behav 2005; 30(5) : 1029-1033. 11. Rollnick S, Heather N, Gold R, Hall W. Development of a short readiness to change questionnaire for use in brief,opportunistic interventions among excessive drinkers. Br J Addict May 1992; 87(5) : 743-54. 12. Jarvik ME, Schneider NG: Nicotine in Substance Abuse: A Comprehensive Textbook Nicotine. Edited by Lowinson JH RPMR. Baltimore, : Williams & Wilkins 1992; pp 334 356. 13. Ray R. The extent, patterns and trends of drug use in India: National Survey. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional office for South Asia 2004. 14. Mohan D, Purohit DR, Sethi BB. Collaborative study on Narcotic drugs and Psychotropic substances. Report submitted to Indian Council of Medical Research 1993. 15. Mohan D. Prevalence of drug abuse among university students. In Mohan D, Sethi H.S. and Tongue E (eds) Current research in drug abuse in India, Gemini Printers, New Delhi 1981, pp 18-31. 16. Currie SR, Hidgins DC, el-guabaly N and Campbell W. Influence of depression and gender on smoking expentancies and temptations in alcoholics in early recovery. J Substance Abuse 2002; 13, 443-458. 17. Kozlowski LT, Jelinek LC and Pope MA. Cigarette smoking cessation among alcohol users: A continuing and neglected problem. Can J Public Health 1986; 77 : 205-207. 18. Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE & Connett JE. The effects of a smoking cessation intervention on 14.5 years mortality. Ann Intern Med 2005; 142 : 233 239. 19. Shoptaw S, Yang X, Frosch D, Nahom D, Jarvik ME. Rawson RA, Ling W. Smoking cessation in methadone maintenance. Addiction 2002; 97 : 1317 1328. 20. Orleans CT, Hutchinson D. Tailoring nicotine addiction treatments for chemical dependency patients. J Substance Abuse Treatment 1993; 10 : 197 208. 21. Sees KL, Clark HW. When to begin smoking cessation in substance abusers. J Substance Abuse Treatment 1993; 10 : 189 195. 22. Clemmey P, Brooner R, Chutuape MA, Kidorf M, Stitzer M. Smoking habits and attitudes in a methadone maintenance treatment population. Drug Alcohol Dependence 1997; 44 : 123 132. 23. Frosch DL, Shoptaw S, Jarvik ME, Rawson RA, Ling W. Interest in smoking cessation among methadone maintained outpatients. J Addict Dis 1998; 17 : 9-19. 24. Richter KP, Gibson C, Ahluwalia JS, Schmelzle KH. Tobacco use and quit attempts among methadone maintenance clients. Am J Public Health 2001; 91 : 296 299. 25. Campbell BK, Wander N, Stark MJ, Holbert T. Treating cigarette smoking in drug-abusing clients. J Subst Abuse Treat 1995; 12 : 89 94. 26. Shoptaw S, Jarvik ME, Ling W, Rawson RA : Contingency management for tobacco smoking in methadone-maintained opiate addicts. Addict Behav 1996; 21 : 409 412. Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 251