Tackling Nicotine Together (TNT) – Systems Change for Smoke-Free Drug and Alcohol Centres

TNT is a cluster randomised controlled trial examining the effectiveness of an organisational systems change intervention at increasing smoking cessation rates in drug and alcohol treatment centres. The project has recruited 34 treatment centres in Qld, NSW, ACT and South Australia. While the primary outcome measure for the trial is client smoking cessation rates at 6 month follow-up, the project is also collecting data on staff attitudes towards addressing smoking, and organisational smoking related policies and practices.

Smoking is the main preventable burden of disease in Australia and a significant cause of high healthcare costs.(3, 4) In Australia 77-95% of people entering drug and alcohol treatment smoke tobacco – 5 times that of the general adult population.(5, 6) This population have heavier nicotine dependence and smoke more cigarettes than the general population.(6-8) As a result, they experience greater tobacco related burden of illness(9) including substantial social and financial costs to themselves, their families, and society.

Surveys show despite high smoking rates, clients treated for substance use are very interested in quitting smoking and are successful in doing so.(6, 10) Large scale trials among alcohol dependent patients show long term smoking quit rates.(8, 11, 12) Trials of methadone patients also saw positive within treatment quit rates, although with a high rate of relapse.(13-15) A review of 24 studies showed smoking cessation enhanced other drug treatment goals as well as significantly reduced smoking rates compared to no treatment.(16) A meta-analysis comparing safety and efficacy of quit interventions during and after addiction treatment, found short term smoking cessation rates comparable.17 Longer-term effects on alcohol abstinence were beneficial if smoking was addressed during rather than after treatment.

Addressing smoking with drug and alcohol clients does not threaten treatment and can improve other treatment outcomes. Tobacco treatment guidelines in Australia(17) and overseas recommend smokers with chemical dependence be offered medication and counselling to assist quitting. Evidence based approaches include: identify smoking status at every visit; advise smokers to quit; assess readiness to quit; provide counselling / pharmacotherapy; consider substance abuse medications that may also help with smoking cessation; follow up on quit attempts.

Drug and alcohol centres rarely offer help to quit smoking and decision to address client smoking or offer interventions is left to individual staff members. Environmental or systems-based factors in treatment settings that reduce smoking being addressed include: lack of smoke-free policies; staff smoking; smoking permissive culture, along with common beliefs that substance abusers don’t want to quit or quitting will impact negatively on other treatment.

A US audit of drug and alcohol facilities found NO systems for consistent, evidence based tobacco treatment or quality improvement. System level changes for smoking involve: a) identifying and recording smoking status; b) promoting staff intervention to support quit attempts; c) dedicating staff to provide quit treatment; and d) promoting organisational policies supporting and providing quit services.  System change models also include the ‘denormalisation of smoking’. Feasibility studies show a system change approach can successfully integrate tobacco treatment into routine care provided by drug and alcohol clinics.

Excerpt from the TNT: An Organisational Change Intervention Manual for Smoking Cessation in Drug and Alcohol Treatment Centres (2014).

In October 2013, specialist ATOD services were invited via an Expression of Interest process to participate as a site in the TNT Project.

80% of eligible ACT services expressed interested and are now part of the Project.

The following ACT specialist drug treatment and support services are participating in the study:

• Toora Women Inc
• Karralika Programs Inc
• Directions
• Canberra Alliance for Harm Minimisation and Advocacy
• Canberra Recovery Service, Salvation Army
• Alcohol and Drug Service, ACT Health
• Ted Noffs Foundation ACT
• Sobering Up Shelter, CatholicCare
• ATODA

The Project is developing regular newsletters to support engagement of sites and stakeholders in the project:

October 2014
December 2014

In December 2014, training is being provided:

Data collection

All ACT sites will receive onsite data collection training from 15 – 17 December 2014.
Smoking Cessation and NRT

All intervention sites with receive smoking cessation and NRT training with Tracy Greenburg on 15 & 16 December 2014. Click here to download the flyer

Drug and Alcohol Review

Special Issue: Australasian Professional Society on Alcohol and other Drugs Conference 2014, 9-12 November 2014, Adelaide, South Australia
Volume 33, Issue Supplement, November 2014
http://onlinelibrary.wiley.com/doi/10.1111/dar.12222/abstract

Abstract:

WORKSHOP: TACKLING NICOTINE TOGETHER: A PARTNERSHIP PROJECT BETWEEN RESEARCH, THE DRUG AND ALCOHOL TREATMENT SECTOR AND THE CANCER COUNCIL NSW FOR TRANSLATIONAL RESEARCH

BILLIE BONEVSKI,1 ASHLEIGH GUILLAUMIER,1 ROBERT STIRLING,2 CARRIE FOWLIE,3 SCOTT WALSBERGER,4 RAE FRY4

1School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia, 2Network of Alcohol and other Drug Agencies, Sydney, New South Wales, Australia, 3 Alcohol Tobacco and Other Drug Association Australian Capital Territory, Canberra, Australian Capital Territory, Australia, 4 Tobacco Control Unit, Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia

Chair’s email: billie.bonevski@newcastle.edu.au

Chair: Billie Bonevski

Issues: Despite very high client smoking rates, traditionally, tobacco has not been a priority within alcohol and other drug treatment and support services.

Approach: Tackling Nicotine Together (TNT) is a National Health and Medical Research Council-funded cluster randomised controlled trial examining the effectiveness of an organisational systems change intervention at increasing the provision of smoking cessation support as part of routine care. It aims to increase smoking cessation rates in drug and alcohol treatment centres. TNT is a partnership that draws together a number of research groups, drug and alcohol sector peak organisations and the Cancer Council NSW.

Key Findings: The project has recruited 34 treatment centres in Queensland, New South Wales, Australian Capital Territory and South Australia. While the primary outcome measure for the trial is client smoking cessation rates at six month follow-up, the project is also collecting data on staff attitudes towards addressing smoking, and organisational smoking related policies and practices.

Implications for Practice or Policy: TNT is a valuable opportunity to strengthen the evidence base for an intervention to address smoking in this setting as well gaining an understanding of the pro- cesses underlying organisational change. TNT will develop procedures and resources for future use, and Cancer Council NSW and the peak organisations can facilitate transfer of findings into policy and practice by refining and implementing the intervention in other organisations.

Implications for Translational Research: Partnerships across sector stakeholders and research end-users in the research process is critical for translation and ensures that the research question, procedures and results are relevant. TNT is a unique example of partnership research which will facilitate translation of the research outcomes and evidence into drug and alcohol treatment sector policy and practice.

Conclusion: The workshop will describe and discuss the experiences of developing a partnership towards a common goal of addressing drug and alcohol client tobacco smoking.

Click here to download ATODA’s presentation at the workshop.