A vast majority of methadone patients smoke; yet in the 30 days before the survey only one out of three facilities provided counseling to any patients and only one out of ten prescribed nicotine replacement therapy to any patients. A dual strategy of requiring clinics to provide comprehensive nicotine dependence services and training staff to provide these services may provide the incentive and support necessary for the widespread adoption of treatment for nicotine dependence in methadone facilities.

Efforts to help smokers in drug treatment quit smoking have met with little success. To explore barriers to quitting and interest in tobacco harm reduction we conducted focus groups and interviews among 78 patients from five Methadone Maintenance Treatment (MMT) sites. Measures included a written survey and open-ended questions on (a) motivation for quitting, (b) what quit methods worked and what didn't work, and (c) interest in smoking reduction and nicotine maintenance as an alternative to complete cessation. Discussions were audiotaped, transcribed, and coded using computer-based qualitative software; our interobserver reliability was 83%. Successful quitters used in general a combination of quit methods such as prayer, nicotine gum, keeping busy, quitting 'one day at a time,' nicotine patches, deep breathing, and avoidance of triggers. Nicotine craving, rather than withdrawal, was cited as the biggest challenge to staying quit. Some current smokers feared quitting smoking would divert them from their goal of quitting illicit drug use or tapering off MMT. Current smokers were interested in smoking reduction as an alternative to quitting; however, those who had tried but failed to reduce smoking preferred complete cessation. Nicotine maintenance was favored by only a few participants with major health problems who didn't hold out hope for quitting. Findings suggest combination pharmacotherapy could help patients control withdrawal and acute episodes of craving. Patients have a number of skills from coping with illicit drug dependence that are useful in combating nicotine dependence. Behavioral methods and short-term pharmacotherapy to help patients reduce tobacco exposure should be explored.

This pilot study is the first to examine the feasibility and outcomes of dual pharmacotherapy for smoking cessation among drug treatment patients. The intervention consisted of 7 weeks of bupropion (300 mg), 12 weeks of nicotine gum, and 6 sessions of motivational interviewing. The trial was conducted among 28 patients recruited from 5 methadone clinics and employed a pretest-posttest design. At 6 months post quit date, 14% of participants met criteria for biochemically-verified abstinence. Among those still smoking, number of cigarettes smoked decreased significantly and most (88%) had made at least 1 serious quit attempt. Participation rates were excellent and no adverse effects on alcohol or illicit drug use were found. Although not a definitive test of the intervention, findings suggest that a multi-component approach to tobacco dependence is feasible and potentially effective in helping drug treatment patients achieve smoking cessation well beyond the end of treatment and that a large-scale randomized trial is warranted.

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Although smoking increases morbidity and mortality among patients in addictions clinics, few clinics provide routine smoking treatment. To understand staff attitudes toward treatment, we surveyed leaders of outpatient methadone treatment clinics nationwide. Our response rate was 59% (408/697). Most clinic leaders thought they should provide smoking treatment (76%) or refer patients for care (91%); however, fewer than half of these had provided treatment in the month prior to the survey. Leaders said smoking treatment would benefit their clinics, patients and communities, but said barriers-primarily insufficient staff training-prevented routine care. Addressing these barriers could increase smoking treatment in addictions clinics and save lives.