Tobacco use and tobacco services in California substance use treatment programs

Ashtray with cigarettesCalifornia has one of the lowest smoking rates in the U.S. However, the California substance use disorder (SUD) treatment system collects no information on tobacco use for clients entering treatment. In a recent article in Drug and Alcohol Dependence, Joseph Guydish, PhD, Kwinoja Kapiteni and colleagues shared their findings on smoking prevalence and tobacco-related services offered to persons enrolled in 20 California residential SUD treatment programs. 
Combining self-reported smokers (60.5 %) with probable smokers (8.4 %), the smoking prevalence was 68.9%. Additionally, 37.9% of smokers wanted help with quitting, 58.8 % had tried to quit in the past year, and 32.7 % were thinking of quitting in the next 30 days. Smokers who wanted help with quitting were more likely to receive advice on how to quit, tobacco-related counseling, referrals, and pharmacotherapy.  
Other findings were less positive. One third of smokers were not asked about smoking status, and 60% did not want help with quitting. Among those who wanted help, about half received no tobacco-related advice or referral, and two-thirds received no cessation medication.   
There are advantages to offering smoking cessation in the context of SUD treatment. From a tobacco control perspective, SUD treatment offers access to a high prevalence smoking population. From a clinical perspective, this population is already seeking help for other (non-tobacco) addictions, and quitting smoking can be supported by the clinical tools used to treat addiction to other SUDs.   

The researchers urge that all clients be asked about their smoking status. Readiness to quit should be assessed to provide cessation services to those who, like the one-third of smokers in the current sample, are thinking of quitting in the next 30 days. Other strategies such as motivational interviewing, groups designed to increase readiness to quit, and reduction of staff smoking could also be utilized to increase the proportion of clients who are interested in quitting.  
While these strategies can de-normalize smoking and support quitting, clients also need tobacco-related services. SUD clients with health insurance, compared to those without, are more likely to be screened for tobacco use and more likely to report a past year quit attempt. California expanded Medicaid under the ACA, and this may account for access to tobacco-related services observed in the current study. However, Medi-Cal, the California Medicaid system, does not reimburse SUD providers for tobacco cessation services in the context of residential treatment. Consequently, California SUD programs have no financial or regulatory incentives to treat smoking, despite the prevalence of smoking, the associated health effects, and the downstream costs to Medi-Cal which insures, in this sample, 70.8 % of clients. 
“The California Department of Healthcare Services (DHCS) manages Medi-Cal funding, which pays for residential SUD treatment,” explained Guydish.  “DHCS offers higher payment rates for programs that treat peri-natal women, on the theory that these clients require more services or more specialized services.  DHCA could also offer higher payment rates for programs that systematically address smoking. This would create a financial incentive for programs to assess and treat tobacco use.”
That clients who want help quitting smoking are more likely to receive such help is encouraging. Still, fewer than half of smokers in this part of the healthcare system wanted help with quitting, and many who wanted help did not receive it. This occurs in a context where smoking is ubiquitous, where the state supports a robust tobacco control program, and where Medicaid expansion covers both residential SUD treatment and tobacco cessation services. The California SUD licensing authority, and the California Medi-Cal authority, should create regulatory and financial incentives for programs to assess and treat tobacco use throughout the statewide SUD treatment system.

“Smoking is a ubiquitous risk factor in SUD treatment, said Guydish. “But we do not measure it, within SUD programs, we do not reimburse treatment for it and we do not treat it. That is the problem.”

Joe GuydishJoesph Guydish, PhD
Dr. Guydish is a professor at the Philip R. Lee Institute for Health Policy Studies. His research concerns access, delivery, and organization of substance abuse treatment services. His experience in this area includes studies evaluating efforts to improve access to publicly funded drug abuse treatment, assessing federal policy to end addiction as an SSI disability category, evaluating needle exchange as an HIV prevention strategy, and investigating interventions for drug-involved offenders. In recent years, Dr. Guydish’s work has focused on tobacco dependence in addictions treatment, because of the high rate of smoking in this population, because of the known health consequences, and because of the increasing evidence that quitting smoking in addictions treatment also improves drug abuse outcomes.

Tobacco use and tobacco services in California substance use treatment programs.
Guydish J, Kapiteni K, Le T, Campbell B, Pinsker E, Delucchi K. Drug Alcohol Depend. 2020 Sep 1;214:108173. doi: 10.1016/j.drugalcdep.2020.108173. Epub 2020 Jul 11.