Understanding tobacco treatment implementation in Veterans Health Administration substance use disorder residential programs

Individuals with a substance use disorder (SUD) are 3 to 4 times more likely to use tobacco than individuals without an SUD. Nicotine dependence leads to more mortality and morbidity than other substances, yet tobacco use is not commonly a focus of SUD treatment. SUD residential treatment programs (SRPs) offer an opportunity to deliver tobacco use treatment (TUT) in a supportive intensive treatment environment. This mixed-method study identified the current status of integrated TUT, predictors of Nicotine Replacement Therapy (NRT) receipt, and barriers and facilitators to implementing integrated TUT in VHA SRPs. TUT provision within SRPs was estimated using VHA fiscal year (FY) 2010 administrative datasets. Approximately, 79% of SRP patients were likely smokers. Of these, only 11% were both diagnosed with and treated for nicotine dependence while in SRP. Ninety-four percent of those treated received NRT. A multivariate mixed-effects logistic regression identified predictors of NRT utilization, including being Caucasian, under 55 years old, or having a nicotine dependence and/or mental health diagnosis. Qualitative interviews with SUD staff from a random, stratified sample of 15 SRPs identified factors enhancing or impeding integrated TUT implementation. Barriers included insufficient resources, lack of training, and staff attitudes. Facilitators included tobacco-free policies, systems to track smoking status and outcomes, and mentoring by SRP programs with successful TUT integration. Nicotine dependence is under-diagnosed and tobacco treatment appears to be under-utilized in SRPs. Our findings demonstrate the need for targeted materials that address staff beliefs and attitudes and provide useful training and systems to support implementation.