Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Open Access

Peer-reviewed

Research Article

Exploring the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from problematic drug or alcohol use: A qualitative systematic review

Abstract

Background

Smoking prevalence and the associated poor health and mortality is significantly higher among people with/recovering from problematic drug or alcohol (PDA) use in comparison with the general population. Evidence from existing systematic reviews shows smoking cessation enhances rather than compromises long-term abstinence from alcohol or drug use. However, these systematic reviews lack important contextual detail around the reasons why uptake of, and successful engagement with existing stop smoking services remains low for people in treatment or recovery from PDA use. This systematic review explores qualitative data on the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from PDA use. This key objective addresses the limited inclusion of qualitative studies in previous systematic reviews on this issue.

Methods

A qualitative systematic review was conducted with searches across four electronic databases (PubMed, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature [CINAHL]). All studies that had a qualitative component about free smoking cessation/reduction programmes for people in treatment or recovery from PDA use were included. Studies that examined electronic smoking or services that required a fee were excluded. Study quality was assessed using National Institute for Health and Care Excellence checklist. Qualitative synthesis involved inductive thematic analysis. (PROSPERO Registration number: CRD42022298521).

Results

8809 potentially eligible articles were identified, 72 full texts were screened and ten articles were included for full review. Barriers to uptake and engagement with existing stop smoking services centered on three key themes: perception of public health importance, programme structure, and intervention elements. Facilitators included supportive treatment environment and optimization of support/staff resources for smoking cessation service delivery.

Conclusion

Recommendations included influencing a change in the way people perceive the importance of smoking cessation activities during PDA use treatment or recovery. There was also some emphasis on the need to create the right environment for sustained adherence to treatment or recovery plans, and deliver the interventions within the health system as comprehensive care. The limited qualitative evidence on community-based and outpatient services highlights a research gap.

Citation: Iyahen EO, Omoruyi OO, Rowa-Dewar N, Dobbie F (2023) Exploring the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from problematic drug or alcohol use: A qualitative systematic review. PLoS ONE 18(7): e0288409. https://doi.org/10.1371/journal.pone.0288409

Editor: Charlotte Lennox, The University of Manchester Division of Psychology and Mental Health, UNITED KINGDOM

Received: February 21, 2023; Accepted: June 26, 2023; Published: July 13, 2023

Copyright: © 2023 Iyahen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Tobacco smoking prevalence among people with/recovering from problematic drug or alcohol (PDA) use is significantly higher than in the general population. The global smoking rates for this group and the associated illnesses and deaths have been estimated to be 2–4 times higher than in the general population [1–6]. People who have PDA use are more likely to suffer from complex comorbidities (including respiratory ill-health associated with smoking) and mental health challenges. Studies have also shown that people with PDA use are more likely to die from smoking than from their alcohol or drug use [7–10].

There are different forms of smoking cessation support available to the general population in different countries [11, 12]. This support involves the use of pharmacological and/or behavioural approaches [5, 13–15]. Pharmacological strategies involve the use of medications such as nicotine replacement therapy (NRT), varenicline and bupropion, while behavioural approach involves individual or group counseling sessions [14, 16–20].

There is a significant evidence base looking at the effectiveness of pharmacological and/or behavioural smoking cessation approaches for the general population. Some studies found some evidence that NRT increases smoking abstinence when used either alone or in combination with behavioural counselling sessions [4–6, 13–15, 21, 22]. Despite this, the uptake of, and successful engagement with existing stop smoking services has remained generally low for the general population especially in the long-term [22–26]. In comparison, the rate at which people in treatment/recovery from PDA use utilize and successfully engage with existing stop smoking services is consistently lower than in the general population [5, 6, 27–29]. Guidance for alternative approaches which promote smoking harm reduction for people in PDA use treatment/recovery have been recently provided by the National Institute for Health and Care Excellence (NICE) [30]. This harm reduction strategy acknowledges that problematic substance use is linked to the socio-economic conditions under which the individual lives [31, 32].

Existing systematic reviews highlight that stop smoking services are effective and also increase the odds of long-term abstinence for people in treatment/recovery from PDA use [4–6]. However, these systematic reviews only considered Randomized Controlled Trials (RCTs) focusing on the effectiveness of existing interventions not the barriers and facilitators to uptake and successful engagement with the services. There is therefore, a lack of contextual detail around the reasons why uptake of, and successful engagement with existing stop smoking services remains low for people in treatment or recovery from PDA use. Addressing this gap is the purpose of this qualitative systematic review. The overall aim of the review was to examine the barriers and facilitators to engagement with smoking cessation programmes for people with/recovering from PDA use.

Smoking cessation programmes were defined as specialized smoking services offered to people who want to stop smoking tobacco [12, 33]. Smoking cessation services are usually delivered within the health systems and evidence to evaluate the delivery and effectiveness exists in developed countries such as the United Kingdom (UK), United States of America (USA) and Australia [34–37]. People enrolled in either residential/inpatient or outpatient treatment programmes for PDA users were considered to be ‘in treatment’, while those who had already received some form of support for their PDA use were considered as people ‘in recovery’. The delivery of this systematic review was guided by two review questions:

  1. What barriers do people with PDA use face when seeking help to cut down or stop smoking?
  2. What factors promote the successful engagement and positive experiences of interaction with stop smoking services for people with/recovering from PDA use?

Methods

Study design

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [38] and Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) [39] guidelines. A protocol for this review was registered with International Prospective Register of Systematic Reviews (PROSPERO) [Identifier: CRD42022298521], S1 Appendix. This review was approved by the Usher Masters Research Ethics Group (UMREG) at the University of Edinburgh, Scotland. Supplementary information for this systematic review includes the PRISMA checklist (S1 File) and ENTREQ checklist (S2 File).

Databases and search strategy

The search strategy was defined using the Participants, Interventions, Comparisons and Outcomes (PICO) framework to which Setting (S) and Type of study (T) have been added [40]. PubMed, Embase, PsycINFO and CINAHL databases were electronically searched for journal articles published from each database’s inception to 19th November 2022. The searches were done using a combination of free text keywords and Medical Subject Headings (MeSH) terms from each database (S1 Fig). Key words were associated with smoking, smoking cessation, substance abuse and treatment/recovery. The search strategy was first developed and tested in PubMed by one reviewer (EI). This strategy was then applied to each of the other databases between 15th and 18th of November 2022. Finalized searches were run across all four databases on 19th November 2022 (S1 Fig). Manual searches of reference lists of key articles were done for supplementary references.

Inclusion and exclusion criteria

In contrast to existing systematic reviews of relevance to this topic which only include randomized control trials (RCTs), this review focused on qualitative studies, mixed method studies (qualitative component only) or qualitative components in the process evaluation of RCTs. Journal articles published in English from database inception to the search date were deemed eligible for review using pre-specified search terms. Primary research studies reporting qualitative findings from all countries where free smoking cessation programmes have been implemented were included. Qualitative studies that reported on smoking cessation support or services that required a fee were excluded. Studies that examined electronic smoking for smoking cessation were also excluded. Systematic reviews were not included but reference lists were scanned as sources of primary studies. People with PDA use were also categorized as having drug dependence or substance use issues [41–43].

Study selection and data extraction

The finalized search terms were run through the four databases and references were exported to Covidence where duplicates were removed and references were stored. Covidence is an online systematic review programme with a simple, user-friendly interface which allows multiple researchers to work in an efficient manner on the same project, through the steps of the systematic review process [44, 45]. Titles of search results were assessed to remove references which were not related to the search parameters. This was done by the principal reviewer (EI) according to pre-determined inclusion criteria, with 10% of the studies excluded (randomly selected) double-checked by a second reviewer (OO) independently. This was aimed at enhancing objectivity and robustness in ascertaining their relevance. Titles and abstracts of studies that were potentially eligible for inclusion underwent duplicate independent review by the two reviewers, based on the same eligibility criteria. Full texts of studies that met our inclusion criteria were retrieved and independently assessed for eligibility by two authors (EI) and (OO). In all cases, disagreements were resolved by discussion with a third reviewer (FD) and a final list of studies for full review was generated.

Data from included articles were extracted using a customized summary sheet as template. The template was first tested with three articles independently by two reviewers and then used to record study aims and country where research was conducted. Other data items included sample characteristics, type of support received and where it was offered, as well as findings and conclusions. Summary of the findings were those of relevance to the objectives of this systematic review only.

Study quality assessment

The principal author (EI) independently assessed the quality of 70% of the included studies using the NICE critical appraisal checklist designed for qualitative studies [46, 47] (S3 File). This was achieved using the guidelines provided for the effective use of the checklist [46] (S2 Appendix). The tool assessed 14 items under unique domains of the qualitative research methods for each included qualitative study, to test the validity of the theoretical approach. An overall assessment of the included studies was done and one of three final gradings which are ++, + and–was given. This grading was based on the number of the checklist criteria that have been fulfilled, and if not fulfilled or adequately described, whether the conclusions were likely to alter or not. This process followed a double blinded assessment strategy where another reviewer (OO) independently assessed 30% of the included studies.

Data synthesis

A thematic analysis of study findings was conducted using an inductive approach [48]. An inductive thematic analysis ensures that the meanings are drawn directly from the data and not shaped by a pre-conceived idea or theoretical framework [48, 49]. Two authors (EI) and (OO) first read through the quotes in the text twice to bring about familiarity with the qualitative data in the included studies. A codebook was developed where data of potential relevance to the research questions were highlighted. Initial codes representing participants’ direct opinions were written verbatim. The initial codes were generated from each data item in the entire body of data. This was done in sequence to ensure inclusivity. Codes were re-read by (OO) to maintain consistency. The initial codes were organized into second-level descriptive codes and codes that conveyed similar meanings were grouped together. The coding process identified the views of service users and treatment providers which were analyzed together. Participants’ verbatim quotes that expressed very similar ideas were first aggregated into third level analytical sub-themes. All closely-related sub-themes that intersected and were precursor to one another but conveyed a central message were organized into themes. The emerging themes were those that directly addressed the research questions.

Results

Search results

The electronic database searches identified 8809 studies which were merged across Covidence. After duplicates were removed, 8529 studies passed through the screening stage, 420 database records underwent title and abstract screening, of which 72 studies met the eligibility for full text review. After screening, seven articles met the inclusion criteria and were eligible for qualitative synthesis. Three more studies were manually sourced by scanning the reference lists of the included studies and added during the inclusion phase of the study selection process. This made the total number of studies for the qualitative systematic review ten (see Fig 1 for PRISMA flow diagram). Seven of the included studies were published between 2013 and 2020; three were published before the year 2010. The reviewed studies were all conducted in high income countries, with eight of the studies carried out in the USA [50–57]. Of the remaining two studies, one was conducted in the UK [58] and another in Australia [59].

thumbnail
Download:
Fig 1. PRISMA flow diagram [60].

https://doi.org/10.1371/journal.pone.0288409.g001

Study characteristics

The included studies all reported qualitative data on tobacco use and/or cessation in PDA use treatment/recovery. Participants were recruited from different drug dependence treatment settings (residential and/or outpatient). Alcohol was the most reported substance in most of the articles included in this review, followed by opioids; the study participants were smokers. Treatment programmes where all offered freely in different state-owned or state-approved PDA use treatment facilities (see Table 1 for study details).

thumbnail
Download:
Table 1. Study details.

https://doi.org/10.1371/journal.pone.0288409.t001

Study quality assessment

The results of the quality assessment of qualitative studies using the 14-item NICE checklist show five studies [50, 51, 53, 54, 59] met all or most of the checklist criteria and were graded (++). Where they were not met, the reasons were either due to poor presentation of findings or lack of adequate details in their conclusions. Three studies [52, 55, 57] fulfilled some of the checklist criteria (8–10) and where they were not fulfilled or were inadequately described by the authors, the conclusions were unlikely to change had alternative approaches been adopted. These studies were graded (+). Two studies [58, 56] met few (six) of the checklist criteria, raising question whether the conclusions would likely or very likely change when alternative methodological and analytical approaches were used to conduct both studies. Both studies were graded (-).

Thematic synthesis

Thematic analysis of extracted smoking cessation related qualitative data identified three broad themes describing the barriers and two broad themes which described the facilitators. The barriers were perception of public health importance, programme structure, and intervention elements. The facilitators included supportive intervention environment as well as optimizing support/treatment staff resources.

Perceived barriers to smoking cessation in PDA use treatment or recovery

Verbatim quotes representing participants’ perception of the barriers people with PDA use face when seeking help to cut down or stop smoking in different PDA use treatment intervention settings are presented under each sub-theme.

Perception of public health importance.

Two sub-themes perceived to influence people’s perception of the public health importance and the consequent low smoking cessation service uptake and successful engagement were lack of priority focus and adequate communication.

Priority issue. A common perception from participants was the view that quitting tobacco use was not as important as getting off the substance which people were in treatment for, or recovering from. This perspective was shared by both PDA use treatment agencies/providers and services users. Many treatment programme administrators expressed concern that tobacco cessation could distract patients from getting off illicit drug use [57], while some thought it was more difficult to achieve [54]. In general, participants attributed less serious health consequences to tobacco use compared to their PDA use. This was commonly cited in residential treatment programmes [51, 53, 55].

“Alcohol’s really toxic. If they come in with hepatitis, it’s hard to argue we should be concentrating on smoking because they’ll smoke for another 20 years. They’re not going to live through this hospitalization if they don’t stop drinking.” [53, p. 341] (Inpatient treatment provider quote)

In other contexts such as community drug/alcohol harm reduction programmes, service users widely reported that smoking cessation was not a priority to treatment providers or agencies [50, 58]. Some treatment providers simply advised patients to delay/defer quitting smoking for various reasons such as the additional responsibility on them to administer smoking cessation services, and fears that it could cause PDA use treatment/recovery relapse. Essentially, the main reason centered on smoking cessation not having the same priority as their PDA use [56, 59].

“… she says to me,’ you’re addressing other things at this time, I don’t think you’re ready to sort this out yet’ (…), she made me not interested.” [58, p. 6] (Community harm reduction service user quote)

Inadequate communication. Smoking status was not considered a part of the initial patient assessment in many residential or inpatient PDA use treatment programmes because low priority was usually attributed to it [53, 59].

“When we assess people first on a consult, we try to think of the whole plan right then. It would make sense to add smoking later, in a follow-up. We’re not focused on it initially because of priority.” [53, p. 341] (Inpatient treatment provider quote)

In contrast, many treatment providers reported that discussions about smoking cessation occurred more frequently in outpatient PDA use treatment facilities even at first contact [59].

“So they do get asked (about smoking) at assessment and we do discuss various techniques, the usual, you know set a date, goal setting, talk about getting NRTs.” [59, p. 95] (Outpatient treatment provider quote)

In other contexts such as community settings, information about smoking cessation was not conveyed in a manner that service users could understand the importance of stopping smoking or make them want to engage with smoking cessation services [50]. Some service users recommended that awareness about the health consequences of tobacco consumption can be better enhanced by using graphics or visual displays of damages to major organs such as the lungs. Other participants accessing similar community services advocated for testimonials or visits to hospitals where people are sick or dying from tobacco-related health issues [50].

Programme structure.

Time and environmental factors inherent in the design and delivery of smoking cessation services in PDA use treatment programmes were commonly cited as barriers to uptake and successful engagement.

Timing. Clients and staff of different PDA use treatment programmes perceived the timing was not right to utilize or engage with existing stop smoking services at the same time people were trying to address their PDA use [50, 52, 57]. Some residential treatment providers expressed the view that attempting to address all problematic substance use at the same time can be overwhelming for service users [53, 54, 56]. Other treatment providers also shared concerns that smoking cessation in the early stages of recovery from PDA use can be stressful and overwhelming for clients [52]. These views were corroborated by patients enrolled in residential and outpatient treatment programmes, respectively [52, 57].

“… ‘There are more important issues at hand’, was what he [staff] was saying. ‘Just don’t use drugs… just don’t worry about the cigarettes right now, because there are bigger fish to fry, so to speak’.” [57, p. s178] (Outpatient service user quote)

Environmental influence. Participants from all of the included studies expressed different views about the impact of the environment where people were receiving support for their PDA use on their ability to successfully engage with stop smoking support. Some respondents were of the opinion that mandatory smoking bans/restrictions in treatment facilities encouraged uptake of stop smoking services. Other participants expressed the view that the smoking restrictions pose a greater challenge for people who prefer to gradually cut-down smoking rather than outright cessation [50, 51, 53].

“If I come off a bus into a programme and nobody’s smoking… no, I’m not gonna want to smoke.” [50, p. 8] (Community service user quote)

Another view expressed was that smoking was a culturally acceptable norm in the ‘recovery community’, involving both treatment providers and service users. They likened it to a normal activity that has gained wide acceptance as a form of drug use in recovery programmes. This is because both treatment providers and service users usually consumed tobacco in settings where people were in recovery from PDA use [51, 54]. Most directors of PDA use residential treatment programmes corroborated this view [55] but felt hypocritical about it [59]. Many treatment providers reported the culture of staff smoking whereas they offered advice to service users against smoking while in treatment/recovery from PDA use. This action discouraged many service users who wanted to stop smoking [55, 59].

“…In certain recovery settings the staff also will take a smoke break with the population and stuff like that … literally everybody in the building … it’s just like a norm … it just seems like it’s accepted.” [51, p. 1086] (Residential service user quote)

Intervention elements.

Services providers and users of PDA use treatment services reported different outcomes of some smoking cessation models such as the use of NRT and quit lines. The majority of the clients were of the view that the smoking cessation methods were not very effective. Whereas, most treatment providers described how limited time and resources affected availability and access to smoking cessation services, as well as how it affected clients’ uptake or successful engagement behavior [50, 52, 57, 59].

Effectiveness of smoking cessation models. Participants from different studies reported different outcomes of the various smoking cessation methods. Many expressed the view that NRT and other pharmaceuticals such as Varenicline (Champix) and quit lines were not effective. Some service providers and users complained that the nicotine patches or gum did not help them stop smoking [50, 52, 57, 59]. Some commonly cited reasons for service users’ perception of the ineffectiveness of smoking cessation approaches included limited cessation service options, poor explanation of quit line services and benefits. Others were the experience or perception of side effects from the use of pharmacotherapy such as NRT and Varenicline. [50, 52, 57, 59].

“Well my (own quitting) experience of NRT has been pretty disappointing. I didn’t really find that it helped at all. But then again I’ve heard other people say that it has helped but, no, I don’t think it was fantastic at all. I wouldn’t use that method again.” [59, p. 95] (Community-based treatment provider quote)

Some service providers in a community drug harm reduction programme expressed some views which they perceived were the reasons for the negative experiences of service users with the different smoking cessation methods. The reasons included service users’ lack of experience with or access to comprehensive smoking cessation services which combine NRT and in-depth counselling and also promote sustained quit lines [50]. In other contexts such as residential PDA use treatment settings, service providers and users expressed the view that behavioural counselling was more effective when patients are stable from the effects of withdrawing the illicit substance, following the period of hospitalization [53].

“Give [me] a couple of days. I got mad when they first mentioned cigarettes.…I told them I wasn’t ready, but now [a few days later] I’m ready.” [53, p. 343] (Inpatient service user quote)

Intensity and coverage of smoking cessation services. Smoking cessation opportunities and approaches were reported to be rarely discussed with service users when they are newly enrolled in PDA use treatment/recovery programmes. Where such conversations were held, they were either not engaging enough or the smoking cessation services available did not include methods/products that patients could have preferentially used and possibly engage with. The most commonly cited reason for the preferences was clients’ report of negative experiences with the use of some smoking cessation methods/products in the past [50, 53–55]. Residential treatment providers also cited lack of resources for staff training and implementation of counseling groups as key barriers that made it difficult to deliver smoking cessation services or willingly offer support when it was their mandate to do so [55, 59].

“So we have the culture from the staff, how they were trained in schools, on the one hand, and we have the culture of the clientele, both of those work against smoking cessation.” [55, p. 24] (MMT provider quote)

It was commonly reported by both health care providers and service users that the costs of the different smoking cessation products such as nicotine patches or gums were not fully covered by the comprehensive smoking cessation services in different PDA use treatment settings. The tobacco cessation treatment options sometimes varied by service users’ insurance plans which limited the smoking cessation services they could benefit from and engage with [55, 50]. In addition to this, the free smoking cessation support offered did not extend beyond the residential period for patients in residential/inpatient programmes [57] or to the follow-up period for those accessing outpatient services [54].

“‘You’re all on your own afterwards.’ The hospital did not provide take-home patches or any form of after-care for nicotine dependence.” [57, p. S178] (Inpatient service user quote)

Perceived facilitators.

The provision of a supportive treatment environment and optimizing support/staff resources for smoking cessation service delivery were the commonly expressed views that could potentially enhance uptake of, and successful engagement with smoking cessation services while in treatment/recovery from PDA use. Verbatim quotes representing participants’ perception of what facilitates smoking cessation service uptake in different PDA use treatment intervention settings are presented under each sub-theme.

Supportive intervention environment.

The participants expressed mixed views about the impact of smoking restrictions during PDA use treatment/recovery (theme 2) but agreed on the need for smoking cessation support to be properly integrated into drug dependence treatment by prioritizing it [53]. Some participants of outpatient programmes also expressed the views that designing smoking cessation services in ways that service users can easily engage with them could facilitate uptake [51, 52, 55, 57]. This could be achieved by having external support from people (like the sponsors in drug dependence treatment programmes). They can closely monitor service users’ progress and readily provide motivations to continue with their efforts at stopping smoking while in treatment/recovery from PDA use [52].

Prioritizing smoking cessation support. Treatment providers expressed some views about actions they perceived could help prioritize smoking cessation support in PDA use interventions and thus, facilitate uptake. Some of the recommended actions included frequent communication, defining drug dependence to include tobacco consumption, and integrating smoking cessation support into smoking-related health issues (essentially for clinic-based interventions) [53, 54].

“I think when you separate out tobacco from other substances; it really makes it a different—it’s like a more benign kind of thing when you and I know that it’s not.” [53, p. 342] (Inpatient treatment provider quote)

Tailoring stop smoking services. Whereas some service users stated that they felt motivated to stop smoking completely by reducing the number of cigarettes they smoked daily, others perceived smoking reduction was ineffective or difficult to sustain and therefore, preferred cessation [57]. Many service users were also of the opinion that increasing the frequency of smoking cessation service delivery (to say, more than once a week) as well as adopting a group-like smoking counseling sessions could facilitate the rate of successful engagement [51].

“We know, up here, that we probably can’t smoke just two or three cigarettes a day. It would be ideal if we could, but we probably can’t. But we’d sure like it if we could. But I know I couldn’t, ever.... It’s not realistic for me. Damn it, I’ve tried! It would have to be all or nothing at all.” [57, p. S180] (MMT service user quote)

Health care providers and users of different PDA use treatment clinics unanimously advocated for more intensive tobacco cessation support. They recommended the creation of specialist units within PDA use treatment programmes or agencies. This should comprise people who can provide ‘real-time’ support [52], act as role models or mentors (being successful quitters), and can effectively communicate the contents of a smoking cessation message [51, 55]. These specialist units were also expected to help maintain engagement through a ‘sponsorship role’ which is similar to what obtains in other drug dependence treatment programmes [52].

“[I wish there was] a person you could talk to more about smoking. A person that knows about quitting and gives out some advice to stop smoking” [51, p. 1086] (Residential service user quote)

Optimizing support/treatment staff resources.

Integrated care through increased staff support was reported to have helped prioritize smoking cessation services for people in PDA use treatment/recovery by surmounting the barriers of time and resource constraints. It also facilitated the delivery of smoking cessation services using the best approaches because of enhanced communication activities [53, 57].

Team-based strategy. Many residential programme administrators said they believed that a team-based approach reduces the burden on treatment providers to deliver smoking cessation support alongside treatment for PDA use [53, 59]. Some service providers acknowledged that many of the general staff might have skills that can be deployed to deliver smoking cessation [53].

“I think everybody on the care team should support smoking cessation. I think for the patients for whom we’re already having in depth discussions about their substance use, the tobacco should be part of it. I also think they should not wait for the consult service for medication, NRT to start.” [53, p. 342] (Inpatient treatment provider quote)

Participants perceived it would be much easier to determine the best timeline to deliver smoking cessation services through this approach. For example, clients and treatment providers in residential programmes reported positive outcomes when discussions about smoking cessation commenced when patients have been stabilized (from substance withdrawal symptoms) [53].

“Give [me] a couple of days. I got mad when they first mentioned cigarettes.…I told them I wasn’t ready, but now [a few days later] I’m ready.” [53, p. 343] (Inpatient service user quote)

In general, many programme directors reported that financial support for delivering stop smoking services including acquiring medications, sustaining engagement (follow-up inclusive), helped increase service users’ uptake and successful engagement [55]. The use of incentives and a reward-based system were perceived as great facilitators of smoking cessation service uptake for people in PDA use treatment/recovery. The reward system included awards of certificates, creation of unique free-time activities for people who had partaken in smoking cessation sessions or have stopped smoking for a period of at least thirty days [55].

Positive communication. Stakeholders described the importance of using appropriate language to communicate smoking cessation activities/plans to service users. Some treatment providers proposed that the message should be framed in ways that conveyed a positive outlook capable of inspiring treatment clients’ confidence in the support offered and their capacity to engage successfully [53, 57]. Many treatment providers noted that framing the message along the line of thought that ‘patients who quit tobacco use would be more successful in stopping the use of other drugs or alcohol’, might motivate them to quit all the substances including tobacco [53]. This view was also expressed by patients receiving methadone treatment for opioid dependence [57].

“There are many observational studies that show that the people who quit smoking do better.’ That’s what I explain to patients and actually patients are very open to hearing that.” [53, p. 342] (Inpatient treatment provider quote)

Congruently, a patient who was receiving methadone treatment for opioid dependence reported that the encouraging tone used by a methadone-dispensing nurse helped him successfully engage with tobacco cessation services and stay quit, upon notifying her of his intention to stop smoking [57].

“She just asked, ‘How?’ I told her that I was thinking about getting on the patch and she said she thought it was fine. She would ask me occasionally how I was doing and if I was still on the patch or whatever. Occasionally, I would tell her that it has been a month, three months; it has been a year or whatever. She would just tell me how proud she was of me.” [57, p. S178] (MMT service user quote)

Discussion

This is the first qualitative systematic review to examine the barriers and facilitators to uptake and engagement with existing stop smoking services for people in treatment/recovery from problematic drug or alcohol use. Results from the thematic analysis indicated that treatment providers and users’ perception of the public health importance of smoking cessation, programme structure, and intervention elements were the commonly reported barriers. Supportive intervention environment and optimization of support/staff resources for smoking cessation services represented key facilitators of patients’ successful engagement with stop smoking services. These broad themes had complex interacting sub-themes which altogether underscored the need to change narratives, create the right environment and consider a comprehensive care approach to addressing the problem. The results of this study will not only provide the contextual details that were lacking in other systematic reviews, but will also help inform future intervention development to help this group cut down or stop smoking in the future.

Changing the narratives

Qualitative evidence from this systematic review has shown that only few of the people in PDA use treatment/recovery programmes actually know the importance of smoking cessation, as opposed to popular views that they are not always willing to consider it [61, 62]. This is because the attention given to smoking cessation and support is limited. It is less and poorly talked about, undermining its relevance to public health. Empirical evidence from observational studies support these views [63, 64].

The evidence that communicating health service strategies in a manner that is both engaging and gives people a better sense of awareness of how relevant the health issue and their responses are to public health, is well reported in the literature [65, 66]. This strategy could increase the chances for successful engagement by taking the harm reduction intention (cessation or reduction) of people in PDA use treatment/recovery into consideration [61].

Creating suitable environment

Environmental factors such as the culture of smoking and delivering smoking cessation support within PDA use treatment were reported to have limited clients’ access to, or engagement with stop smoking services [50, 51, 53, 55]. This is considered a major limiting factor associated with PDA use treatment implementation [67, 68]. The mixed views about environmental factors have also been extensively examined in systematic reviews [69, 70] and different quantitative studies [1, 11, 62, 71, 72].

The impact of these ‘environmental’ factors on PDA use treatment/recovery outcomes is well recognized [73, 74]. People’s social networks exert more influence on their behaviour the closer these networks are to them [75]. The specialist units many respondents in our qualitative synthesis advocated for which they perceived comprise ‘champions’ [51, 55], could exert this influence. Bringing in an external stop smoking advisor/service and/or peer supporters such as clients who have stopped smoking might be needful in delivering smoking cessation services within PDA use treatment programme structure.

Considering comprehensive care

There is a considerable existing evidence base demonstrating the effectiveness of pharmacotherapy in smoking cessation, either alone or in combination with behavioural approaches [4–6]. Availability and accessibility of smoking cessation approaches differed based on the free smoking cessation services that were comprehensively offered [50, 55, 57]. This makes it difficult to achieve smoking cessation goals within PDA use treatment programme structure because better outcomes in drug dependence treatment are derived for example, from medium to long-term support [76, 77]. Currently, no evidence explains what the scope of stop smoking services (quality and access) implies for people with PDA use that are in recovery or have left the residential treatment facility.

In general, the way PDA use treatment services are offered does not prioritize smoking cessation services over the other treatment demands it competes for [63, 64, 78]. Studies have recommended a comprehensive care approach which requires detailed assessment of needs and a flexible recovery plan that can be reviewed [77, 79–81]. This approach allows tailoring stop smoking services to meet clients’ needs [82] especially in resource-constrained settings [83]. Evidence supports the idea that integrated care can significantly influence smoking cessation/reduction outcomes because it offers support along the continuum of care [84–86]. This is needed to improve treatment quality and clients’ access/engagement [81].

Strengths and limitations

A particular strength of this systematic review is its focus on qualitative studies, with existing quantitative studies mostly focused on outcome evaluation of smoking cessation services. Evidence suggests that people disengage from treatment when they do not feel motivated to continue, or feel unsatisfied with treatment or when the support is not sustained [67, 87]. Future qualitative studies should seek to examine in greater detail, perspectives from community-based and outpatient services.

A significant limitation of this systematic review is that it does not include as much qualitative evidence from community-based and outpatient contexts as residential/inpatient harm reduction services. Studies examining the effectiveness of smoking cessation interventions in these contexts are limited, despite a significant reduction in the number of residential visits as observed in the USA and UK for example [36, 88–90]. This represents a significant research gap in the literature that future researches need to address.

Another limitation is that this review has not synthesized evidence from low-income countries. Generally, studies that have examined stop smoking behaviours in the relevant cultural and socioeconomic contexts of developing countries where the burden of smoking is highest [12] are limited [91]. This gap in literature affects the transferability of findings from this systematic review to low-income settings.

Conclusion

Public health practitioners/commissioners working in smoking cessation services need to examine evidence from all drug dependence treatment contexts. This will help them to adequately devise and assess the feasibility of targeted tobacco harm reduction strategies which are aimed at assisting a stigmatized population to reduce or stop smoking. PDA use treatment providers need to influence a change in the way people perceive the importance of smoking cessation activities during PDA use treatment/recovery. They also need to place more emphasis on the need to create suitable environment for sustained adherence to treatment/recovery plans as well as deliver PDA use treatment interventions within the health system as comprehensive care. This will enhance patients’ uptake and successful engagement with existing stop smoking services especially in residential/inpatient treatment programmes. These efforts would ease the burden on health care systems from the health issues and preventable deaths that are direct consequences of tobacco use.

References

  1. 1. Guydish J, Le T, Hosakote S, Straus E, Wong J, Martínez C, et al. Tobacco use among substance use disorder (SUD) treatment staff is associated with tobacco-related services received by clients. Journal of Substance Abuse Treatment. 2022 Jan;132:108496. pmid:34111773
  2. 2. Lien L, Bolstad I, Bramness JG. Smoking among inpatients in treatment for substance use disorders: prevalence and effect on mental health and quality of life. BMC Psychiatry. 2021 May 11;21(1). pmid:33975577
  3. 3. Weinberger AH, Gbedemah M, Wall MM, Hasin DS, Zvolensky MJ, Goodwin RD. Cigarette use is increasing among people with illicit substance use disorders in the United States, 2002–14: emerging disparities in vulnerable populations. Addiction. 2018 Dec 19;113(4):719–28. pmid:29265574
  4. 4. Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders. Cochrane Database of Systematic Reviews. 2016 Nov 23. pmid:27878808
  5. 5. Thurgood SL, McNeill A, Clark-Carter D, Brose LS. A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine & Tobacco Research. 2015 Jun 11;18(5):993–1001. pmid:26069036
  6. 6. Prochaska JJ, Delucchi K, Hall SM. A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Journal of Consulting and Clinical Psychology. 2004 Dec;72(6):1144–56. pmid:15612860
  7. 7. de Dios MA, Cano MÁ, Childress S, Vaughan E, Cerna Y, Niaura R. Smoking Status and Substance Use Treatment Outcomes Among Spanish Speakers Enrolled in Substance Abuse Treatment. Journal of Clinical Psychology. 2016 Apr 19;72(10):1037–48. pmid:27092710
  8. 8. Martin RA, Cassidy RN, Murphy CM, Rohsenow DJ. Barriers to Quitting Smoking Among Substance Dependent Patients Predict Smoking Cessation Treatment Outcome. Journal of Substance Abuse Treatment. 2016 May;64:7–12. pmid:26979552
  9. 9. Hurt RD, Offord KP, Croghan IT, Gomez-Dahl L, Kottke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA [Internet]. 1996 Apr 10 [cited 2021 Dec 30];275(14):1097–103. Available from: https://pubmed.ncbi.nlm.nih.gov/8601929/ pmid:8601929
  10. 10. Hser YI, Mccarthy WJ, Anglin MD. Tobacco Use as a Distal Predictor of Mortality Among Long-Term Narcotics Addicts. Preventive Medicine. 1994 Jan;23(1):61–9. pmid:8016035
  11. 11. Knudsen HK, Studts CR, Studts JL. The Implementation of Smoking Cessation Counseling in Substance Abuse Treatment. The Journal of Behavioral Health Services & Research [Internet]. 2011 Jun 7 [cited 2022 Aug 3];39(1):28–41. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3189278/
  12. 12. World Health Organization. WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies [Internet]. apps.who.int. World Health Organization; 2017. Available from: https://apps.who.int/iris/handle/10665/255874
    • 13. García-Gómez L, Hernández-Pérez A, Noé-Díaz V, Riesco-Miranda JA, Jiménez-Ruiz C. Smoking Cessation Treatments: Current Psychological and Pharmacological Options. Revista de investigacion Clinica [Internet]. 2019 Feb 4;71(1). Available from: https://www.medigraphic.com/pdfs/revinvcli/nn-2019/nn191b.pdf pmid:30810545
    • 14. Akanbi MO, Carroll AJ, Achenbach C, O’Dwyer LC, Jordan N, Hitsman B, et al. The efficacy of smoking cessation interventions in low‐ and middle‐income countries: a systematic review and meta‐analysis. Addiction. 2019 Jan 2; 114(4):620–35. pmid:30506845
    • 15. Dobbie F, Hiscock R, Leonardi-Bee J, Murray S, Shahab L, Aveyard P, et al. Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study. Health Technology Assessment. 2015 Nov; 19(95):1–156. pmid:26565129
    • 16. Yilmazel Ucar E, Araz O, Yilmaz N, Akgun M, Meral M, Kaynar H, et al. Effectiveness of pharmacologic therapies on smoking cessation success: three years results of a smoking cessation clinic. Multidisciplinary Respiratory Medicine [Internet]. 2014 Feb 4;9(1):9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3916028/ pmid:24495744
    • 17. Wu P, Wilson K, Dimoulas P, Mills EJ. Effectiveness of smoking cessation therapies: a systematic review and meta-analysis. BMC Public Health [Internet]. 2006 Dec;6(1). Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-6-300 pmid:17156479
    • 18. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. The Cochrane Database of Systematic Reviews [Internet]. 2005 Apr 18;(2):CD001007. Available from: https://pubmed.ncbi.nlm.nih.gov/15846610/ pmid:15846610
    • 19. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Systematic Reviews. 2017 Mar 31;3(3).
    • 20. WHO report on the global tobacco epidemic 2019: offer help to quit tobacco use. World Health Organization [internet]. 2019:1–118. Available from: https://www.who.int/publications/i/item/9789241516204
      • 21. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. The Cochrane database of systematic reviews [Internet]. 2008;(1):CD000146. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18253970/ pmid:18253970
      • 22. Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews [Internet]. 2016 Sep 13; Available from: https://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose pmid:27622384
      • 23. Reid MS, Selzer J, Rotrosen J. Smoking cessation treatment at substance abuse rehabilitation programs. Northeast ATTC Resource Links [Special Issue on Smoking Cessation Treatment and Substance Use Disorders] [Internet] 2006; 5(2):2–5 [cited 2021 November 20]. Available from: http://ctndisseminationlibrary.org/PDF/156.pdf
      • 24. Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews. 2016 May 9. pmid:27158893
      • 25. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews [Internet]. 2014 Jan 8 [cited 2022 Jul 26]; Available from: https://pubmed.ncbi.nlm.nih.gov/24402784-antidepressants-for-smoking-cessation/ pmid:24402784
      • 26. Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews. 2012 Nov 14;11.
      • 27. Skelton E, Guillaumier A, Tzelepis F, Walsberger S, Paul CL, Dunlop AJ, et al. Alcohol and other drug health‐care providers and their client’s perceptions of e‐cigarette use, safety and harm reduction. Drug and Alcohol Review. 2021 Mar 28;40(6):998–1002. pmid:33774886
      • 28. Baca CT, Yahne CE. Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment. 2009 Mar;36(2):205–19. pmid:18715746
      • 29. Miller ME, Sigmon SC. Are Pharmacotherapies Ineffective in Opioid-Dependent Smokers? Reflections on the Scientific Literature and Future Directions. Nicotine & Tobacco Research [Internet]. 2015 Aug 1 [cited 2022 Jan 16];17(8):955–9. Available from: pmid:26180219
      • 30. NICE. Tobacco: preventing uptake, promoting quitting and treating dependence NICE guideline [Internet]. 2021. Available from: https://www.nice.org.uk/guidance/ng209/resources/tobacco-preventing-uptake-promoting-quitting-and-treating-dependence-pdf-66143723132869
        • 31. Stratton KR, Shetty P, Wallace R, Bondurant S, editors. Clearing the smoke: assessing the science base for tobacco harm reduction. Washington, D.C.: Institute of Medicine, National Academy Press (US); 2001.
          • 32. Lenton S, Single E. The definition of harm reduction. Drug and Alcohol Review. 1998 Jun 1; 17(2):213–9. pmid:16203486
          • 33. Drope J, Cahn Z, Kennedy R, Liber AC, Stoklosa M, Henson R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA: A Cancer Journal for Clinicians. 2018 Sep 29;67(6):449–71.
          • 34. Kale D, Gilbert H, Sutton S. An exploration of the barriers to attendance at the English Stop Smoking Services. Addictive Behaviors Reports. 2019 Jun;9:100141. pmid:31193736
          • 35. Cookson C, Strang J, Ratschen E, Sutherland G, Finch E, McNeill A. Smoking and its treatment in addiction services: Clients’ and staff behaviour and attitudes. BMC Health Services Research [Internet]. 2014 Jul 14 [cited 2022 Oct 31];14(1). Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-304 pmid:25017205
          • 36. Friedmann PD, Jiang L, Richter KP. Cigarette smoking cessation services in outpatient substance abuse treatment programs in the United States. Journal of Substance Abuse Treatment. 2008 Mar;34(2):165–72. pmid:17509809
          • 37. Bryant J, Bonevski B, Paul C, O’Brien J, Oakes W. Delivering smoking cessation support to disadvantaged groups: a qualitative study of the potential of community welfare organizations. Health Education Research. 2010 Sep 30; 25(6):979–90. pmid:20884732
          • 38. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Journal of Clinical Epidemiology [Internet]. 2009 Oct;62(10):1006–12. Available from: https://pubmed.ncbi.nlm.nih.gov/19631508/ pmid:19631508
          • 39. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Medical Research Methodology [Internet]. 2012;12(1):181. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23185978 pmid:23185978
          • 40. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a Comparison Study of Specificity and Sensitivity in Three Search Tools for Qualitative Systematic Reviews. BMC Health Services Research [Internet]. 2014 Nov 21;14(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310146/ pmid:25413154
          • 41. Buchanan J. Understanding problematic drug use: a medical matter or a social issue? British Journal of Community Justice. 2006 Jan 01; 4(2):387–97.
          • 42. Mekonen T, Fekadu W, Chane T, Bitew S. Problematic Alcohol Use among University Students. Frontiers in Psychiatry. 2017 May 19; 8(86). pmid:28579966
          • 43. Paglia A, Room R. Preventing substance use problems among youth: a literature review and recommendations. The Journal of Primary Prevention [Internet]. 1999 [cited 2021 Nov 4];20(1):3–50. Available from: https://link.springer.com/article/10.1023%2FA%3A1021302302085
          • 44. Harrison H, Griffin SJ, Kuhn I, Usher-Smith JA. Software tools to support title and abstract screening for systematic reviews in healthcare: an evaluation. BMC Medical Research Methodology. 2020 Jan 13; 20(1). pmid:31931747
          • 45. Babineau J. Product Review: Covidence (Systematic Review Software). Journal of the Canadian Health Libraries Association / Journal de l’Association des bibliothèques de la santé du Canada. 2014 Aug 1;35(2):68.
          • 46. NICE. Appendix H Quality appraisal checklist—qualitative studies: Methods for the development of NICE public health guidance (third edition) Process and methods [Internet]. 2012. Available from: https://www.nice.org.uk/process/pmg4/resources/methods-for-the-development-of-nice-public-health-guidance-third-edition-pdf-2007967445701
            • 47. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in qualitative evaluation: a framework for assessing research evidence. London: Government Chief Social Researcher’s Office. [Internet]. 2003. Available from: https://dera.ioe.ac.uk/21069/2/a-quality-framework-tcm6-38740.pdf
              • 48. Braun V, Clarke V. Using Thematic Analysis in Psychology. Qualitative Research in Psychology. 2006; 3(2):77–101.
              • 49. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, Calif.: Sage Publications; 2002.
                • 50. Berman BA, Jones L, Jones F, Jones A, Pacheco BA, McCarthy WJ. How can we help African American substance users stop smoking? client and agency perspectives. Journal of Ethnicity in Substance Abuse. 2019 Dec 19; 18(3):428–44. pmid:29257942
                • 51. Bhuiyan J, Jonkman L, Connor S, Giannetti V. Qualitative evaluation of perceptions of smoking cessation among clients at an alcohol and other drug treatment program. Research in Social and Administrative Pharmacy. 2017 Nov; 13(6):1082–9. pmid:27856209
                • 52. Fallin A, Miller A, Ashford K. Smoking Among Pregnant Women in Outpatient Treatment for Opioid Dependence: A Qualitative Inquiry. Nicotine & Tobacco Research. 2016 Jan 27; 18(8):1727–32. pmid:26817489
                • 53. Kathuria H, Seibert RG, Cobb V, Weinstein ZM, Gowarty M, Helm ED, et al. Patient and Physician Perspectives on Treating Tobacco Dependence in Hospitalized Smokers With Substance Use Disorders: A Mixed Methods Study. Journal of Addiction Medicine. 2019 Sep; 13(5):338–45. pmid:31232740
                • 54. McCool RM, Paschall Richter K. Why do so many drug users smoke? Journal of Substance Abuse Treatment. 2003 Jul; 25(1):43–9. pmid:14512107
                • 55. Pagano A, Tajima B, Guydish J. Barriers and Facilitators to Tobacco Cessation in a Nationwide Sample of Addiction Treatment Programs. Journal of Substance Abuse Treatment. 2016 Aug; 67:22–9. pmid:27296658
                • 56. Richter KP. Good and Bad Times for Treating Cigarette Smoking in Drug Treatment. Journal of Psychoactive Drugs. 2006 Sep 1;38(3):311–5. pmid:17165374
                • 57. Richter KP, McCool R, Okuyemi K, Mayo M, Ahluwalia J. Patients’ views on smoking cessation and tobacco harm reduction during drug treatment. Nicotine & Tobacco Research. 2002 Dec 1; 4(4):175–82. pmid:12573178
                • 58. Garner L, Ratschen E. Tobacco smoking, associated risk behaviours, and experience with quitting: a qualitative study with homeless smokers addicted to drugs and alcohol. BMC Public Health. 2013 Oct 10; 13(1). pmid:24112218
                • 59. Wilson AJ, Bonevski B, Dunlop A, Shakeshaft A, Tzelepis F, Walsberger S, et al. “The lesser of two evils”: A qualitative study of staff and client experiences and beliefs about addressing tobacco in addiction treatment settings. Drug and Alcohol Review. 2015 Aug 31;35(1):92–101. pmid:26332170
                • 60. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an Updated Guideline for Reporting Systematic Reviews. British Medical Journal [Internet]. 2021 Mar 29;372(71):n71. Available from: https://www.bmj.com/content/372/bmj.n71
                • 61. Campbell BK, Le T, Tajima B, Guydish J. Quitting smoking during substance use disorders treatment: Patient and treatment-related variables. Journal of Substance Abuse Treatment. 2017 Feb;73:40–6. pmid:28017183
                • 62. Guydish J, Passalacqua E, Tajima B, Manser ST. Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: a review. Journal of Psychoactive Drugs. 2007 Jul 22;39(4):423–433. pmid:18303699
                • 63. Goodwin RD, Wu M, Davidson L. An empirical perspective on cigarette use in substance use recovery. Psychological Medicine. 2021 Jul 15;51(14):2299–306. pmid:34261564
                • 64. Rogers ES, Gillespie C, Smelson D, Sherman SE. A Qualitative Evaluation of Mental Health Clinic Staff Perceptions of Barriers and Facilitators to Treating Tobacco Use. Nicotine & Tobacco Research. 2017 Sep 7;20(10):1223–30.
                • 65. Rogers RW. Cognitive and physiological processes in fear appeals and attitude change: a revised theory of protection motivation. In: Cacioppo JT, Petty RE, editors. Social Psychophysiology: A Source Book. New York: Guilford Press; 1983. p.153–76.
                  • 66. Conner M, Norman P. Health behaviour. In: Asmundson GJGeditor. Comprehensive Clinical Psychology (second edition) [Internet]. Amsterdam, Netherlands: Elsevier; 2022. p. 1–33. Available from: https://doi.org/10.1016/B978-0-12-818697-8.00060-1
                    • 67. Brorson HH, Ajo Arnevik E, Rand-Hendriksen K, Duckert F. Drop-out from addiction treatment: A systematic review of risk factors. Clinical Psychology Review. 2013 Dec;33(8):1010–24. pmid:24029221
                    • 68. Jawad I, Watson S, Haddad PM, Talbot PS, McAllister-Williams RH. Medication nonadherence in bipolar disorder: a narrative review. Therapeutic Advances in Psychopharmacology [Internet]. 2018 Oct 16;8(12):349–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6278745/ pmid:30524703
                    • 69. Gentry S, Craig J, Holland R, Notley C. Smoking cessation for substance misusers: A systematic review of qualitative studies on participant and provider beliefs and perceptions. Drug and Alcohol Dependence. 2017 Nov;180:178–92. pmid:28910690
                    • 70. Twyman L, Bonevski B, Paul C, Bryant J. Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature. BMJ Open [Internet]. 2014 Dec 1;4(12):e006414. Available from: https://bmjopen.bmj.com/content/4/12/e006414 pmid:25534212
                    • 71. Ziedonis DM, Zammarelli L, Seward G, Oliver K, Guydish J, Hobart M, et al. Addressing Tobacco Use Through Organizational Change: A Case Study of an Addiction Treatment Organization. Journal of Psychoactive Drugs. 2007 Dec;39(4):451–9. pmid:18303702
                    • 72. Williams J, Foulds J, Dwyer M, Orderconnors B, Springer M, Gadde P, et al. The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey. Journal of Substance Abuse Treatment. 2005 Jun;28(4):331–40. pmid:15925267
                    • 73. Tones K. Devising strategies for preventing drug misuse: the role of the Health Action Model. Health Education Research [Internet]. 1987 [cited 2022 Sep 16];2(4):305–17. Available from: https://www.jstor.org/stable/45111045#metadata_info_tab_contents
                    • 74. Baric L, MacArthur C. A study of health education aspects of smoking in pregnancy. International Journal of Health Education [Internet]. 1976 Apr 1 [cited 2022 Sep 17];2(suppl). Available from: https://research.birmingham.ac.uk/en/publications/a-study-of-health-education-aspects-of-smoking-in-pregnancy
                    • 75. Green J, Cross R, Woodall J, Tones K. Health promotion: planning and strategies. Los Angeles: Sage; 2019.
                      • 76. Cheng H-Y, McGuinness LA, Elbers RG, MacArthur GJ, Taylor A, McAleenan A, et al. Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis. BMJ. 2020 Nov 25;m3934. pmid:33239318
                      • 77. Marchand K, Beaumont S, Westfall J, MacDonald S, Harrison S, Marsh DC, et al. Patient-centred care for addiction treatment: a scoping review protocol. BMJ Open. 2018 Dec;8(12):e024588. pmid:30593556
                      • 78. Rogers E, Sherman S. Tobacco Use Screening and Treatment by Outpatient Psychiatrists Before and After Release of the American Psychiatric Association Treatment Guidelines for Nicotine Dependence. American Journal of Public Health. 2014 Jan;104(1):90–5. pmid:24228666
                      • 79. Public Health England. Adult substance misuse treatment statistics 2019 to 2020: report [Internet]. GOV.UK. 2020. Available from: https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2019-to-2020/adult-substance-misuse-treatment-statistics-2019-to-2020-report
                        • 80. Evashwick CJ. Creating a continuum. The goal is to provide an integrated system of care. Health Progress (Saint Louis, Mo) [Internet]. 1989 Jun 1;70(5):36–9, 56. Available from: https://pubmed.ncbi.nlm.nih.gov/10293328/ pmid:10293328
                        • 81. Substance Abuse and Mental Health Services Administration (US), Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. PubMed. Washington (DC): US Department of Health and Human Services; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424857/
                          • 82. Pype P, Mertens F, Helewaut F, Krystallidou D. Healthcare teams as complex adaptive systems: understanding team behaviour through team members’ perception of interpersonal interaction. BMC Health Services Research. 2018 Jul 20;18(1). pmid:30029638
                          • 83. O’Brien P, Crable E, Fullerton C, Hughey L. Best practices and barriers to engaging people with substance use disorders in treatment. Washington, D.C: Truven Health Analytics [Internet]. 2019. Available from: https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//187391/BestSUD.pdf
                            • 84. Hubbard RL, Craddock SG, Flynn PM, Anderson J, Etheridge RM. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors. 1997 Dec;11(4):261–78.
                            • 85. Hubbard RL, Craddock SG, Anderson J. Overview of 5-year followup outcomes in the drug abuse treatment outcome studies (DATOS). Journal of Substance Abuse Treatment. 2003 Oct;25(3):125–34. pmid:14670518
                            • 86. Simpson DD, Joe GW, Brown BS. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors. 1997 Dec;11(4):294–307.
                            • 87. Alderson H, Spencer L, Scott S, Kaner E, Reeves A, Robson S, et al. Using Behavioural Insights to Improve the Uptake of Services for Drug and Alcohol Misuse. International Journal of Environmental Research and Public Health. 2021 Jun 28;18(13):6923. pmid:34203334
                            • 88. Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services (N-SSATS) 2020: Data on Substance Abuse Treatment Facilities. [Internet]. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2021. Available from: National Survey of Substance Abuse Treatment Services | CBHSQ Data (samhsa.gov)
                              • 89. Fuller BE, Guydish J, Tsoh J, Reid MS, Resnick M, Zammarelli L, et al. Attitudes toward the integration of smoking cessation treatment into drug abuse clinics. Journal of Substance Abuse Treatment. 2007 Jan;32(1):53–60. pmid:17175398
                              • 90. Office for Health Improvement and Disparities. Adult substance misuse treatment statistics 2020 to 2021: report [Internet]. 2021. Available from: https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report
                                • 91. Chean K-Y, Goh LG, Liew K-W, Tan C-C, Choi X-L, Tan K-C, et al. Barriers to smoking cessation: a qualitative study from the perspective of primary care in Malaysia. BMJ Open [Internet]. 2019 Jul;9(7):e025491. Available from: https://bmjopen.bmj.com/content/9/7/e025491 pmid:31289057