Addressing Smoking Cessation among Women in Substance Use Treatment: A Qualitative Approach to Guiding Tailored Interventions

Abstract

Intersecting socially marginalized identities and unique biopsychosocial factors place women with substance use disorders (SUDs) experiencing myriad disadvantages at higher risk for smoking and stigmatization. Here, based on our work with women receiving care for SUDs in four participating treatment/women-serving centers (N = 6 individual clinics), we: (1) describe the functions of smoking for women with SUDs; and (2) explore participants’ experiences of a comprehensive tobacco-free workplace (TFW) program, Taking Texas Tobacco-Free (TTTF), that was implemented during their SUD treatment. Ultimately, information gleaned was intended to inform the development of women-tailored tobacco interventions. Data collection occurred pre- and post-TTTF implementation and entailed conducting client (7) and clinician (5) focus groups. Using thematic analysis, we identified four main themes: “the social context of smoking,” “challenges to finding support and better coping methods,” “addressing underlying conditions: building inner and outer supportive environments,” and “sustaining support: TFW program experiences.” Women reported that: smoking served as a “coping mechanism” for stress and facilitated socialization; stigmatization hindered quitting; non-stigmatizing counseling cessation support provided alternative coping strategies; and, with clinicians, the cessation opportunities TTTF presented are valuable. Clinicians reported organizational support, or lack thereof, and tobacco-related misconceptions as the main facilitator/barriers to treating tobacco addiction. Effective tobacco cessation interventions for women with SUDs should be informed by, and tailored to, their gendered experiences, needs, and recommendations. Participants recommended replacing smoking with healthy stress alleviating strategies; the importance of adopting non-judgmental, supportive, cessation interventions; and the support of TFW programs and nicotine replacement therapy to aid in quitting.

Organizational Factors Moderating Changes in Tobacco Use Dependence Care Delivery Following a Comprehensive Tobacco-Free Workplace Intervention in Non-Profit Substance Use Treatment Centers

“…Regardless of the clientele or specificity of the non-nicotine substance use treatment provided within the participating centers, the training of clinicians on the use of the five As was invariant, as too was its intended application across patients. The Taking Texas Tobacco Free program also sponsored clinicians to obtain specialized trainings (i.e., Certified Tobacco Treatment Specialist training and Motivational Interviewing); these components of the program are detailed elsewhere [ 33 , 34 , 35 , 38 , 39 , 40 ]. Each participating center could avail themselves of these specialized trainings, which had a much broader scope than training on the five As.…”

“…Taking Texas Tobacco Free has been implemented throughout Texas in behavioral health treatment settings and substance use treatment centers [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. Implementation outcome data have supported significant increases in tobacco-related knowledge among employees, increases in clinicians’ self-reported use of the five As, and increases in organizational capacity for tobacco intervention provision to patients [ 33 , 34 , 35 , 36 , 37 , 39 , 40 , 41 ].…”

“…Behavioral health treatment facilities see a greater number of unique patients annually and employ a greater number of employees [ 33 , 37 , 45 , 46 , 47 ]. Additionally, substance use treatment centers may treat more specialized patient populations than behavioral health treatment facilities: while behavioral health facilities may broadly serve adults or children [ 48 ], substance use treatment centers may serve specific patient populations (e.g., patients who are sexual minorities, women and their children, patients with a disability) or patients with specific use disorders (e.g., opioid use) [ 38 , 49 , 50 , 51 ]. Results elucidating the organizational moderators impacting tobacco control program implementation among substance use treatment centers, specifically, can be used to optimize the implementation and maintenance of tobacco-free workplace programs within these settings.…”

Implementation and Outcomes of a Comprehensive Tobacco Free Workplace Program in Opioid Treatment Centers

“…Pre- to post-implementation results demonstrated gains in both clinical and non-clinical employee education, increased use of tobacco use assessments and evidence-based cessation practices, increased rate of tobacco cessation among non-clinical employees, and higher demand for NRT [ 28 ]. In 2017, TTTF was scaled-out to smaller, more independent, less well-resourced, and more population- or disorder-specific, non-profit substance use treatment centers [ 25 , 31 ] and community agencies [ 32 ]. This effort included implementation within several OUD treatment centers, which are the subject of this report.…”

Organizational-Level Moderators Impacting Tobacco-Related Knowledge Change after Tobacco Education Training in Substance Use Treatment Centers

“…The training included education on the dangers of tobacco use, the addictiveness of nicotine, the prevalence of tobacco use among individuals with non-nicotine substance use disorders, the tobacco industries’ targeting of individuals with behavioral health needs, and empirically-based methods to address tobacco use disorder (including the importance of tobacco-free workplace policies and how to uphold them). Several other components of the TTTF program were enacted thereafter as detailed elsewhere [ 14 , 28 , 29 , 34 , 35 , 36 , 37 , 38 ], including sending program champions to Certified Tobacco Treatment Specialist trainings, Motivational Interviewing trainings, etc., but are not the subject of this report. Program champions are individuals who are identified by the center to lead and be the primary contact for implementation of the tobacco-free workplace program within their center.…”