The Health Belief Model and smoking cessation behaviours

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Addictive Behaviors

journal homepage: www.elsevier.com/locate/addictbeh

Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study

Hasmeena Kathuriaa,⁎, Ryan G. Seibertb, Vinson Cobba, Nicole Herbstb, Zoe M. Weinsteinc, Minda Gowartya, Reha Jhunjhunwalad, Eric D. Helma, Renda Soylemez Wienera,e

a The Pulmonary Center, Boston University School of Medicine, Boston, MA, United States of America b Division of General Internal Medicine, Boston University School of Medicine, Boston, MA, United States of America c Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine/Boston Medical Center, Boston, MA, United States of America d Program of Clinical Investigation, Boston University School of Medicine, Boston, MA, United States of America e Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, United States of America

H I G H L I G H T S

• Cigarette use in hospitalized SUD smokers was 3-fold higher than non-SUD smokers. • Heroin use disorder patients described how cigarettes potentiate their heroin high. • Many SUD patients are turning to vaping and e-cigarettes to quit smoking. • Smoking-related health events motivated SUD patients to quit smoking cigarettes. • SUD patients perceived clinicians do not prioritize treating tobacco dependence.

A R T I C L E I N F O

Keywords: Substance use disorders Tobacco dependence treatment Hospitalized smokers Addiction medicine Smoking cessation Heroin use

A B S T R A C T

Aims: Smoking cessation may promote long-term recovery in patients with substance use disorders (SUD). Yet smoking rates remain alarmingly high in this population. Using a sequential explanatory mixed methods ap- proach, we examined smoking rates among hospitalized patients with SUD at a large safety-net hospital, and then characterized factors associated with smoking behaviors both quantitatively and qualitatively. Method: We abstracted data from all hospital admissions (7/2016–6/2017) and determined demographics, substance use type, and other characteristics associated with cigarette use among those with SUD. We then conducted semi-structured qualitative interviews with 20 hospitalized SUD smokers. We analyzed transcripts to characterize factors that affect patients' smoking habits, focusing on the constructs of the Health Belief Model. Results: The prevalence of cigarette smoking among hospitalized smokers with SUD was three times higher than those without SUD. Qualitative analyses showed that patients perceived that smoking cigarettes was a less serious concern than other substances. Some patients feared that quitting cigarettes could negatively impact their recovery and perceived that clinicians do not prioritize treating tobacco dependence. Almost all patients with heroin use disorder described how cigarette use potentiated their heroin high. Many SUD patients are turning to vaping and e-cigarettes to quit smoking. Conclusion: Hospitalized patients with SUD have disproportionately high smoking rates and perceive multiple barriers to quitting cigarettes. When designing and implementing smoking cessation interventions for hospita- lized patients with SUD, policymakers should understand and take into account how patients with SUD perceive smoking-related health risks and how that influences their decision to quit smoking.

1. Introduction

There has been a dramatic decline in smoking rates in the United

States, but less success among vulnerable populations including the less educated, the poor, and those with mental illness and substance use disorders (SUD) (Bandiera, Anteneh, Le, Delucchi, & Guydish, 2015;

https://doi.org/10.1016/j.addbeh.2019.02.017 Received 21 October 2018; Received in revised form 16 February 2019; Accepted 17 February 2019

⁎ Corresponding author at: Pulmonary Center, 72 E Concord St R304, Boston, MA 02118, United States of America. E-mail address: [email protected] (H. Kathuria).

Addictive Behaviors 95 (2019) 41–48

Available online 18 February 2019 0306-4603/ © 2019 Elsevier Ltd. All rights reserved.

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Jamal et al., 2016). Despite efforts to promote smoking cessation in these populations, the prevalence of smoking cigarettes among SUD individuals remains extremely high (Kalman et al., 2001; Weinberger et al., 2018; Weinberger, Funk, & Goodwin, 2016). In fact, the pre- valence of cigarette smoking in the US has increased from 2002 to 2014 among those with SUD and declined among people without SUDs (Weinberger et al., 2018). While studies show promising outcomes with pharmacotherapy and/or contingency management (Apollonio, Philipps, & Bero, 2016; Nahvi, Ning, Segal, Richter, & Arnsten, 2014; Richter & Ahluwalia, 2000; Rohsenow et al., 2015; Rohsenow et al., 2017; Rohsenow, Martin, Tidey, Colby, & Monti, 2017), quit rates among SUD smokers are consistently lower than in the general smoker population (Miller & Sigmon, 2015). Not only do those with SUD smoke more heavily and have more difficulty quitting, they also have higher tobacco-related illness and mortality (Goodwin et al., 2014; Hser, McCarthy, & Anglin, 1994; Hurt et al., 1996; Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2002; Schroeder & Morris, 2010; Weinberger, Platt, Jiang, & Goodwin, 2015).

Hospital-based smoking cessation interventions offer an opportunity to engage these vulnerable patients who may not independently seek tobacco dependence treatment. Studies in addiction treatment centers show a high prevalence of cigarette smoking among SUD patients, particularly those with opioid use disorder (OUD) (Kalman, Morissette, & George, 2005). However, little is known about the prevalence of smoking in hospitalized SUD patients, particularly by SUD type. Meanwhile, although barriers to quitting cigarettes in the general po- pulation (Macnee & Talsma, 1995; Orleans, Rimer, Cristinzio, Keintz, & Fleisher, 1991; Pomerleau, Zucker, Namenek Brouwer, Pomerleau, & Stewart, 2001; Villanti, Bover Manderski, Gundersen, Steinberg, & Delnevo, 2016) and vulnerable populations (Twyman, Bonevski, Paul, & Bryant, 2014) are well described, fewer studies describe perceived barriers specific to SUD smokers nor the most effective interventions that match their needs and preferences (Asher et al., 2003; Foster, Schmidt, & Zvolensky, 2015; Martin, Cassidy, Murphy, & Rohsenow, 2016; McHugh et al., 2017).

Using a sequential explanatory mixed methods approach (Fetters, Curry, & Creswell, 2013; Ivankova, Creswell, & Stick, 2006), we first analyzed characteristics of smokers with SUD, including by specific il- licit drug, compared to those without SUD, admitted to a large safety- net hospital. Guided by the Health Belief model (HBM) (Hochbaum, 1958), we then qualitatively examined perceived beliefs, attitudes, and barriers to quitting cigarettes among hospitalized SUD smokers.

2. Materials and methods

The institutional review board at Boston University Medical Campus approved this study.

2.1. Quantitative data

2.1.1. Data sources and study population We used Boston Medical Center's (BMC) Clinical Data Warehouse

(CDW), which contains comprehensive data consolidated from the Epic electronic health record (EHR) fields for BMC, the teaching affiliate for Boston University School of Medicine. From the CDW, we identified all adults (age > 18 years) hospitalized at BMC between July 1, 2016 through June 30, 2017 (n = 16,977). We also used the CDW to identify the subset of patients during the study period seen by BMC's Tobacco Treatment Consult (TTC) service (n = 888), which provides tobacco treatment for hospitalized smokers.

2.1.2. Smoking rates and associated factors among hospitalized patients with and without SUD

For all hospitalized patients, we collected EHR data on (1) demo- graphics, (2) smoking status (current, former, never, unknown), (3) current use of substances (alcohol, cocaine, cannabis, hallucinogens,

stimulants, sedatives, opiates [heroin, misuse of prescription pain re- lievers]), (4) comorbid mental health disorders (schizophrenia, de- pression, anxiety, psychosis), (5) use of nicotine replacement therapy (NRT) during hospitalization. Patients were identified as SUD patients if substance use was listed as a primary or secondary discharge diagnosis or on their discharge problem list; and/or a consult was ordered to the inpatient Addiction Consult Service (ACS) (Trowbridge et al., 2017).

For the subset of smokers seen by the TTC (n = 888), we reviewed TTC notes and abstracted data on motivation to quit, Fagerstrom test for nicotine dependency, smoking pack-years, and acceptance of to- bacco treatment components (inpatient counseling, inpatient NRT, re- ferral to outpatient counseling, prescriptions for outpatient NRT). The measure of motivation to quit [3 items: low (not at all motivated), moderate (somewhat motivated), high (very motivated)] was TTC specialist rating of “best estimate of motivation to quit” based on in- formation from the TTC visit, a measure shown to be accurate in pre- dicting 6 and 12-month quit rates in hospitalized smokers (Sciamanna, Hoch, Duke, Fogle, & Ford, 2000).

2.1.3. Statistical analyses Categorical variables were summarized using frequency with per-

centage. We used chi-squared analyses for between group comparisons, with two-sided p-value ≤.05 considered statistically significant. Relative risks (RR) with 95% confidence intervals (CI) were calculated to compare smoking rates between patients with and without SUD overall and stratified by relevant subgroups, defined by demographics and mental health disorders.

2.2. Qualitative data

To characterize factors driving high smoking rates among SUD pa- tients, we conducted 20 semi-structured interviews with hospitalized SUD smokers consulted on by the BMC ACS between July–September 2017 (Table 2). Patients were eligible if they had an active SUD, were current smokers, spoke English fluently, and had no cognitive impair- ments. Patients were excluded if they were unable to be interviewed due to acute illness, somnolence, or cognitive impairment. Thirty con- secutive, eligible smokers were invited to participate; 20 agreed (67%).

Similar to other studies in this population (Azbel, Rozanova, Michels, Altice, & Stöver, 2017), patients expressed discomfort with audio-recording. Therefore at least 3 team members were present for each interview to take detailed field notes, which were then compiled into a single transcript for each interview. Participants self-reported demographic data and SUD history. Interviewers explored patients' beliefs, perceived benefits and barriers to quitting, and how other substances and conversations with clinicians about their addictions affected motivation to quit smoking (Appendix 1). Our semi-structured interview guide was informed by the HBM (Hochbaum, 1958), which theorizes that people's beliefs about whether they are at risk for a health problem, and perceived benefits and barriers of taking action to avoid it, influence readiness to take action. Key constructs include perceived susceptibility, severity, benefits, barriers, self-efficacy and “cues to ac- tion,” which activate readiness to change and may prompt altering a health behavior (Hochbaum, 1958).

Transcripts were analyzed using both deductive and inductive content analysis (Elo & Kyngäs, 2008; Pope, Ziebland, & Mays, 2000). For deductive analysis, collected data were mapped to selected HBM constructs. For inductive analysis, we performed unstructured coding of transcripts to allow for identification of unexpected themes. Selected team members reviewed the first several transcripts and developed a preliminary coding matrix. At least three reviewers manually coded all transcripts in full. Through constant comparison and iterative discus- sions with the full team, we reached consensus on codes and summary categories represented in the data. After finalization of themes grouped in each category, we identified quotes highlighting specific themes.

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3. Results

3.1. Quantitative analysis

3.1.1. Smoking rates among hospitalized patients with and without SUD Among 16,977 unique patients admitted to the hospital, 2729

(16.1%) had at least one SUD and 4294 (25.3%) were current smokers. Documentation as using hallucinogens (n = 2), stimulants (n = 0), se- datives (n = 1), cannabis (n = 72)) either as a single diagnosis or co- morbid with alcohol, cocaine, or opioids was low and therefore ex- cluded from further analysis. Current smoking was significantly more common among patients with SUD (1758/2729, 64.4%) than without SUD (2536/14,248, 17.8%) [χ2 (1) = 2634.4, p < .00001] (Fig. 1). Smoking rates differed significantly by type of SUD [χ2 (3) = 84.2, p < .00001]. Smoking rates were more common in those using opiates (352/476, 73.9%) compared to cocaine (77/126, 61.1%; χ2 (1) = 8.0, p < .005) or alcohol (659/1192, 55.3%; χ2 (1) = 49.6, p < .00001), but not polysubstance use (670/935, 71.7%; χ2 (1) = 0.14, p = .71).

Overall, hospitalized patients with SUD had a > 3-fold increased risk of current cigarette smoking, as compared to those without SUD (RR 3.6, 95% CI 3.4–3.8). This pattern persisted across all subgroups defined by age, sex, race, ethnicity, insurance type, and mental health disorders (Table 1).

3.1.2. Smoking characteristics and acceptance of tobacco treatment among hospitalized patients with and without SUD

Overall, 36.5% (642/1758) of SUD smokers received NRT while hospitalized. Among SUD patients approached by the TTC service, 96.3% (364/378) accepted inpatient counseling, 54.5% (206/378) and 53.4% (202/378) accepted inpatient and outpatient NRT respectively, and 27.2% (103/378) accepted a referral for follow-up at discharge. There were no differences in acceptance of these components between patients with and without SUD (Table 2). However, more non-SUD smokers than SUD smokers had low levels of nicotine dependency (29.1% vs 39.6%, p < .001) and high motivation to quit (50.8% vs 41.8%, p < .008).

3.2. Qualitative analysis

Qualitative analysis sought to understand factors driving these high rates of smoking among hospitalized SUD patients, revealing four dominant themes related to the HBM: (1) the extent to which SUD patients realize the health-related effects of smoking (perceived sus- ceptibility and severity of smoking-related health events); (2) perceived barriers to smoking cessation; (3) abstinence from their primary sub- stance first, especially from heroin, promotes smoking cessation; and

(4) smoking-related health events and hospitalization motivate patients to quit cigarettes (cues to action). We describe these themes using key constructs of the HBM in detail below. In addition, we identified two unanticipated themes: (5) most patients with heroin OUD described how cigarettes potentiate their heroin high; and (6) many SUD patients perceive vaping and e-cigarettes as helpful to quitting cigarettes. Characteristics of interview participants are shown in Table 3; their demographics were typical of hospitalized SUD smokers (Table 1). Most

Fig. 1. Smoking status among hospitalized adults with and without SUD.

Table 1 Relative risk of current smoking among hospitalized adults with SUD, versus those without SUD.

Smoking rates among patients with SUD

Smoking rates among patients without SUD

RR (95% CI)

Overall 1758 / 2729 (64.4%)

2536 / 14,248 (17.8%)

3.6 (3.4–3.8)

Age in years, n (%) 18–54 1140 / 1651

(69.0%) 1434 / 6356 (22.6%)

3.1 (2.8–3.3)

≥ 55 618 / 1078 (57.3%)

1102 / 7892 (14.0%)

4.1 (3.8–4.4)

Sex Male 1152 / 1835

(62.8%) 1457 / 6636 (22.0%)

2.9 (2.6–3.1)

Female 606 / 894 (67.8%)

1079 / 7612 (14.2%)

4.8 (4.3–5.3)

Race White 808 / 1190

(67.9%) 1062 / 5327 (19.9%)

3.4 (3.1–3.7)

Black 723 / 1134 (63.8%)

1009 / 5574 (18.1%)

3.5 (3.2–3.9)

Other 227 / 405 (56.0%)

465 / 3347 (13.9%)

4.0 (3.4–4.7)

Unknown 213 / 382 (55.8%)

395 / 2889 (13.7%)

4.1 (3.4–4.8)

Ethnicity Hispanic 247 / 455

(54.3%) 378 / 2886 (13.1%)

4.1 (3.5–4.9)

Non-Hispanic 1510 / 2273 (66.4%)

2153 / 11,341 (19.0%)

3.5 (3.3–3.7)

Health insurance Medicaid 1599 / 2393

(66.8%) 1990 / 9911 (20.1%)

3.3 (3.1–3.6)

Non-medicaid 159 / 336 (47.3%)

546 / 4337 (12.6%)

3.8 (3.1–4.5)

Mental health disorder

Any 842 / 1238 (68.0%)

674 / 2888 (23.3%)

2.9 (2.6–3.2)

None 916 / 1491 (61.4%)

1862 / 11,360 (16.4%)

3.7 (3.5–4.1)

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participants had low education and income, and many were un- employed or homeless.

3.2.1. Theme 1: Perceived susceptibility and severity of smoking-related health events

Some patients lacked insight into the harmful health effects of ci- garettes. “I'm here for a heart attack and it was because of the mix of heroin and cocaine. Cigarettes didn't contribute.” (P9, Heroin and Cocaine use) Most patients, however, realized the harms of smoking cigarettes and the long-term health benefits of smoking cessation: “It (cigarettes) doesn't kill you as fast, but in the long haul you're going to have something wrong with you. I think quitting cigarettes is just as important.” (P7, Heroin OUD).

Despite cognitively knowing that smoking has detrimental health effects, many patients did not really believe they were personally sus- ceptible to adverse health events from tobacco, particularly when jux- taposed against competing risks of other substances: “I know in reality that cigarettes aren't good, but in my mind I think nothing will happen.” (P14, Heroin OUD) Most patients perceived that smoking cigarettes was a less serious and immediate health concern than other substances: “Smoking doesn't ruin your life. It's not an immediate worry. I use fentanyl, heroin, and I can die. You don't light a cigarette and drop dead.” (P19, Heroin OUD).

3.2.2. Theme 2: perceived barriers to smoking cessation Patients expressed multiple barriers to quitting cigarettes. Some

were common to the general population including smoking for enjoy- ment and to manage stress and boredom. Other barriers to quitting were common to vulnerable populations such as lack of support systems and the addictive nature of nicotine (Table 4). Patients described en- vironmental factors, such as higher exposure to tobacco in settings such as methadone clinic and mistrust and misinformation of medications as barriers to quitting. We also identified unique barriers to quitting ci- garettes perceived by SUD patients. Patients discussed how they ignore their overall health when actively using drugs. Some patients feared smoking cessation would negatively impact their recovery. These themes with illustrative quotes are described below and in Table 3.

Constant exposure to tobacco: Patients viewed their environment as a barrier to quitting: “At a methadone clinic, everyone in line is smoking and it's a trigger.” (P12, Heroin OUD). Mistrust and misinformation of medications: Patients reported mistrust and misinformation with smoking cessation medications, particularly varenicline (Chantix), often reporting their source of information was from peers and commercials: “Chantix makes you suicidal. I've heard in detox, it makes people suicidal.” (P11, Heroin and Cocaine use). Lack of smoking cessation support from health professionals: Patients perceive that compared to other substances, clinicians do not priotitize smoking cessation: “They were more concerned with the drugs than the cigarettes.” (P18, Heroin and Cocaine use) Patients discussed how most clinicians did not offer strategies, particularly pharmacotherapy, to quit smoking: “I've never heard of any other medications. I've seen Chantix only on commercials. No one talks to me about them.” (P7, Heroin OUD). When high, little concern about health: Participants often stated that addiction to drugs in and of itself is a barrier to both smoking ces- sation and investment in their overall health: “When I use drugs, I'm not thinking about my health. …The last thing I think about is quitting smoking.” (P11, Heroin and Cocaine use). Smoking cessation may negatively impact recovery: While most believed quitting cigarettes would have no effect on quitting other substances, some patients expressed concerns that quitting smoking would threaten sobriety: “When you cut down cigarettes, it's hard to stay clean.” (P3, Cocaine use) Moreover, some participants believed smoking might help quitting other substances: “Smoking takes my

Table 2 Smoking characteristics and acceptance of tobacco treatment components (SUD versus No SUD).

Total (n = 888)

SUD (n = 378)

No SUD (n = 510)

p-Value

Inpatient counseling accepted

855 (96.3%) 364 (96.3%) 491 (96.3%) p < .99

Inpatient NRT accepted

457 (51.5%) 206 (54.5%) 251 (49.2%) p < .12

Outpatient referral accepted

229 (25.8%) 103 (27.2%) 126 (24.7%) p < .39

Outpatient NRT accepted

446 (50.2%) 202 (53.4%) 244 (47.8%) p < .10

Fagerstrom Low (< 3) 312 (35.1%) 110 (29.1%) 202 (39.6%) p < .001 High (> 8) 327 (36.8%) 153 (40.5%) 174 (34.1%) p < .052

Motivation to quit Low 297 (33.4%) 138 (36.5%) 159 (31.2%) p < .096 Moderate 135 (15.2%) 65 (17.2%) 70 (13.7%) p < .15 High 417 (47%) 158 (41.8%) 259 (50.8%) p < .008

Pack years > 30 468 (52.7%) 193 (51.1%) 275 (53.9%) p < .40

Table 3 Characteristics of qualitative interview participants.

Total N = 20 Age 46.3 (range 24–61) 18–24 1 (5%) 25–44 6 (30%) 45–54 10 (50%) 55–64 3 (15%)

Male 11 (55%) Race White 14 (70%) Black or African American 3 (15%) Other 3 (15%)

Ethnicity Hispanic 7 (35%) Non-Hispanic 13 (65%)

Health insurance Medicaid 17 (85%) Non-medicaid 2 (10%) Don't know 1 (5%)

Non-tobacco substance use Opiate (heroin +/− other opiate) use only 7 (35%) Alcohol use only 5 (25%) Cocaine use only 2 (10%) Opiate (heroin +/− other opiate) and alcohol use 1 (5%) Both opiate (heroin +/− other opiate) and cocaine use 4 (20%) Opiate (heroin +/− other opiate), alcohol and cocaine use

1 (5%)

Cigarettes (average number per day) 15 (range 2–40) Personal income $0–$35,000 16 (80%) $35,000–$70,000 1 (5%) Did not answer/did not know 3 (15%)

Employment status Full-time 1 (5%) Part time 2 (10%) Unemployed 14 (70%) Disabled 3 (15%)

Marital status Married 1 (5%) Never married 14 (70%) Separated/divorced 5 (25%)

Homeless 14 (70%) Education Some high school 3 (15%) Graduated high school 9 (45%) Some college 4 (20%) Associate/bachelor's degree 4 (20%)

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mind off my cravings to do crack or heroin” (P11, Heroin and Cocaine use).

3.2.3. Theme 3: drug abstinence before smoking cessation A dominant theme from participants was they would have increased

success in quitting cigarettes if they first abstained from other sub- stances: “When I use heroin or use alcohol, I smoke. If I quit heroin, I wouldn't smoke so I want to quit that first.” (P17, Heroin and Alcohol use) A minority believed simultaneously quitting tobacco and other substances would improve their ability to quit all substances: “When I stopped smoking, I did good with everything.” (P7 Heroin OUD).

3.2.4. Theme 4: cues to action Many patients thought it was important to quit smoking and ex-

pressed interest in quitting, “Very important. Quitting [cigarettes] is one of my goals” (P17, Alcohol and Heroin OUD). Patients reported symptoms and hospitalization made them more cognizant of their smoking be- haviors and the health consequences of smoking.

Health events, symptoms and disease severity motivates cessation: Patients who had smoking-related health concerns were more in- terested in quitting: “Finding out I had COPD gives me pause about dangers [of smoking].” (P8, Alcohol use). Hospitalization promotes cessation: Patients reported hospitaliza- tion heightened their awareness of smoking's harms, making them more receptive to health risk messages. When physicians discussed tobacco dependence, it motivated them to consider quitting cigar- ettes.

“‘You have to quit,’ the doctor tells me. The reason I'm in the hospital is for all three of them [substances]. That's why I want to quit all three. …If I didn't get hospitalized, I would be drinking, smoking, and using.” (P17, Heroin and Alcohol use).

3.2.5. Theme 5: heroin use increases a desire or need for cigarettes Almost every participant with OUD (+/− comorbid other SUD)

stated that when they use heroin, they smoke substantially more ci- garettes. “(A) cigarette right after heroin is perfect, it quenches my thirst. Heroin and cigs are like PB&J.” (P14, Heroin OUD).

The opposite was not true:

“When I get high, I smoke like a chimney. It does something to make you want nicotine. I've never smoked and said I want a bag a dope.” (P14, Heroin OUD).

“Cigarettes don't trigger heroin.” (P5, Heroin OUD).

3.2.6. Theme 6: vaping and e-cigarettes An unexpected theme was many SUD patients, regardless of sub-

stance use type, are turning to vaping e-cigarettes to quit smoking.

“I've used gum, vapes, patches. Vaping helped me the most.” (P1, Alcohol use)

“I could work with vaping. Inhaling it is like smoking.” (P18, Heroin and Cocaine use)

On the other hand, some were concerned about side effects: “No e- cigarettes, they got a bunch of chemicals and stuff in it. When I want to quit, I just quit. I don't need those fake things.” (P19, Heroin OUD).

4. Conclusions

The findings of this sequential explanatory mixed methods study add to the evidence of the widening disparity in smoking behaviors among people with SUD versus those without SUD. Analyzing data from 16,977 adults admitted to a safety-net hospital, we found the pre- valence of cigarette smoking to be three times higher among SUD pa- tients than those without SUD, a pattern persisting in every subgroup

Table 4 Perceived barriers to quitting cigarettes.

Barrier Representative quotes

Barriers common to the general population Enjoyment of cigarettes “I enjoy smoking, it calms my nerves.” (P2, Cocaine use disorder)

“Every time a cigarette tastes good to me. That is the problem.” (P14, Heroin use disorder) Stress and boredom “I know how harmful cigarettes are. At the moment, that's all I have. I have to deal with the stressors first.

Cigarettes help me get through them.” (P14, Heroin use disorder)

Barriers common to low income populations Lack of structure and/or support system “I want to quit smoking. …It's important, but not at the top of the to-do list. To bring it to the top, I need to have

more of a schedule. Working, diet, going to the gym would help. Structure/routine would help me quit cigarettes.” (P7, Heroin use disorder) “There's more time I need to fill if I quit both.” (P6, Alcohol use disorder)

Addictive Nature of Nicotine “I think nicotine is the most addictive substance. I don't want my legacy to be dying from cigarettes, but I don't know if I can stop.”(P11, Heroin and Cocaine use disorder) “I left the hospital last time just because I wanted a cigarette.” (P18, Heroin and Cocaine use disorder)

Environment “When you're around smoke, it makes you want it.” (P16, Heroin and Alcohol use disorder) “On the streets there's nothing to do but smoke and do drugs.” (P14, Heroin use disorder)

Misinformation and mistrust with smoking-cessation mediations “You can't smoke and have the patch at the same time. I heard that's real bad for you.” (P12, Heroin use disorder) “I've heard of Chantix and Wellbutrin. Chantix gives you depression but helps you quit. The side effects are worse than smoking.” (P10, Heroin use disorder)

Barriers unique to SUD patients When high, little concern about health “When I'm nodding off from being high, I smoke cigarettes, and I'm not thinking about quitting.” (P18, Heroin and

Cocaine use disorder) Heroin use increases cigarette cravings “When I use heroin, I definitely smoke more. They go hand-in-hand.” (P13, Heroin use disorder)

“If I had $50, I have two options. I would spend $40 on heroin and then have $10 to spend on cigarettes or a cab. I'd always choose cigarettes. When I do heroin, I crave cigarettes. I don't have an answer for it. My body just craves it.” (P18, Heroin and Cocaine use disorder)

Smoking cessation may negatively impact recovery/smoking to cope with urges from other drugs

“If I could continue to smoke a little, it would help me stay sober.” (P6, Alcohol use disorder) “Cigarettes are my safety when I try to quit [other drugs]. Relaxes me.” (P4, Heroin and Cocaine use disorder)

Lack of support from health professionals “I didn't know there were medications to quit” (P5, Heroin use disorder) “I've never been offered smoking medications and patches in combination.” (P11, Heroin and Cocaine use disorder)

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analyzed. Semi-structured interviews with hospitalized SUD patients informed our understanding of factors driving high smoking rates and barriers to quitting cigarettes. Our study adds additional information on patterns of use and barriers not previously described in SUD smokers, including the striking behavioral observation of heroin increasing the desire for cigarettes. Our discussion focuses on how our results might influence future interventions to promote smoking cessation among hospitalized SUD smokers.

To our knowledge, our study is the first to characterize smoking rates of hospitalized SUD patients by substance type; we found parti- cularly high rates among hospitalized OUD patients. Our findings are consistent with studies in addiction treatment centers showing the high prevalence of cigarette smoking in SUD patients, and especially OUD patients (Goodwin et al., 2014; Guydish et al., 2016; Kalman et al., 2005; Pajusco et al., 2012; Pakhale et al., 2018; Weinberger et al., 2016; Weinberger et al., 2017). Seeking to probe this relationship, our qua- litative analysis revealed almost all patients with heroin OUD described how smoking cigarettes after using heroin enhanced their heroin high, making quitting cigarettes nearly impossible if they were actively using heroin. If this behavioral observation holds true in other studies, modifying existing instruments that assess barriers to quitting in SUD patients (Martin et al., 2016) to include items such as ‘I crave cigarettes after using heroin” may be warranted. De-normalizing this behavioral pattern is critical to helping patients quit both substances. Little is known about how to achieve smoking cessation among heroin-depen- dent patients. Laboratory-based human self-administration studies show that heroin administration increases smoking (Kohut, 2017; Mello, Mendelson, Sellers, & Kuehnle, 1980), which may relate to the shared neurobiological processes between nicotine and opiates that trigger dopamine in the brain's reward pathway (Goodman, 2008). Medications that target nicotinic, dopaminergic, and opioid mediators may provide novel treatment approaches for nicotine polysubstance use.

Patients in this study discussed several barriers to quitting cigarettes including concerns commonly expressed by the general population such as smoking as a way to relieve stress (Villanti et al., 2016). Addressing general barriers in hospitalized SUD smokers are particularly im- portant; a study showed that among SUD smokers undergoing smoking treatment, general barriers predicted continued smoking at one month (Martin et al., 2016). Similarly, we identified several perceived barriers to quitting described in other vulnerable populations (Twyman et al., 2014) that were particularly relevant to this SUD population: (1) the local environment (e.g. constant cigarette exposure from peers); (2) mistrust and misinformation regarding medications; and (3) lack of perceived smoking cessation support from clinicians. Recent policy initiatives, such as smoke-free policies in substance use treatment centers and public housing, may help address environmental factors that perpetuate smoking behaviors (Krauth & Apollonio, 2015; Levy, Adamkiewicz, Rigotti, Fang, & Winickoff, 2015; Winickoff, Gottlieb, & Mello, 2010). It is incumbent on clinicians to support smoking cessation attempts and address misinformation about tobacco treatment medi- cations, particularly given recent studies showing the efficacy and safety of varenicline in treating tobacco dependence in patients with psychiatric disease (Anthenelli et al., 2016) and the promise of var- enicline for methadone-maintained smokers (Nahvi et al., 2014).

We also identified barriers specific to SUD smokers. Many hospita- lized SUD smokers in our study perceived cigarettes were a less serious health threat than other substances, again indicating a need for healthcare professionals to counsel SUD patients to correct mis- information about susceptibility and severity of smoking-related illness. Moreover, many patients in our study feared becoming overwhelmed in addressing tobacco and SUD together. As in prior studies (Asher et al., 2003; McHugh et al., 2017), some patients worried smoking cessation would negatively impact their recovery. On the contrary, several stu- dies show smoking abstinence does not lead to a compensatory increase in other drug use and may even improve drug abstinence (Anthenelli

et al., 2016; Prochaska, Delucchi, & Hall, 2004; Thurgood, McNeill, Clark-Carter, & Brose, 2016; Weinberger et al., 2017). Most patients believed they would have increased success in quitting cigarettes if they first quit other substances. A minority, however, preferred quitting all substances simultaneously. Recognizing these different views is im- portant in considering treatment strategies: while all smokers should be encouraged to quit at some point during treatment of their primary SUD, the timing of smoking cessation interventions should be tailored to patient preferences. Message framing about benefits of quitting, such as informing patients that quitting cigarettes may prevent relapse from other substances, may be particularly helpful in motivating smoking cessation.

Our study suggests that hospitalization may serve as an effective cue to action to motivate the desire to quit smoking, if reinforced by counseling and pharmacotherapy from clinicians. Although SUD pa- tients expressed several barriers to smoking cessation, they also re- cognized the health benefits of quitting. Many hospitalized SUD pa- tients think it is important to quit smoking and want to quit, just as in the general population (Jamal et al., 2016). Similar to reports from patients without SUD, health concerns and events motivated smoking cessation in SUD patients (Boudreaux et al., 2010; McBride, Emmons, & Lipkus, 2003; McBride & Ostroff, 2003). Our quantitative analysis showed that 96.3% of SUD patients, regardless of motivation to quit cigarettes, accepted inpatient tobacco counseling and over half ac- cepted NRT. Clinicians should therefore capitalize on hospitalization and/or smoking-related health events as an opportunity to deliver ef- fective messages to encourage smoking cessation, as is recommended by guidelines regardless of diagnosis and clinical condition (2008 PHS Guideline Update Panel, 2008; Fiore & Adsit, 2016).

When considering strategies to cut back or quit smoking, many SUD patients discussed how they perceive vaping and/or e-cigarettes as helpful. Prevalence of e-cigarette and dual use (combustible and e-ci- garette use) is high among SUD patients (Cummins, Zhu, Tedeschi, Gamst, & Myers, 2014; Hefner et al., 2016). E-cigarettes appeal to many SUD patients (Pratt, Sargent, Daniels, Santos, & Brunette, 2016; Stein et al., 2015; Stein et al., 2016), partly due to beliefs that e-cigarettes are less harmful than combustible tobacco and could help reduce smoking (Peters et al., 2015). However, findings are mixed as to whether e-ci- garette use results in higher rates of quitting cigarettes among high-risk smokers with SUD (Hefner et al., 2016; Stein et al., 2016). Additional studies are needed to assess the long-term impact of e-cigarettes in this population.

Our study has strengths and limitations. A strength was the focus on the understudied and underserved population of SUD patients admitted to a safety-net hospital, with a particularly high prevalence of smoking cigarettes. We characterized smoking prevalence data by substance type, which is not consistently reported. A limitation is that data on smoking and other substance use is based on self-report without bio- chemical confirmation. For the qualitative component, patient partici- pants were interviewed during their hospitalization, thus minimizing recollection bias on how acute health events motivated smoking ces- sation. Our participation rate was high, though the small sample size from a single recruitment site limits generalizability.

While our study was limited to SUD smokers, it is likely that hos- pitalized smokers without SUD similarly have misperceptions about the risks of smoking and benefits of cessation, an area in need of further study.

Novel tobacco treatment and outreach strategies for the increasing proportion of the US population with SUD are urgently needed. SUD patients need to be educated on the benefits of smoking cessation which include an increased chance of remission from SUD and improved overall health. This study shows it is essential to understand and take into account how SUD patients perceive smoking-related health risks and how that influences their decision to quit smoking. Only then can effective methods of communicating risk and delivering tobacco treat- ment interventions be achieved to improve quit rates and health

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outcomes in this vulnerable population.

Primary source of funding

This work was supported by the Boston University Evans Center for Implementation and Improvement Sciences (CIIS) and supported in part by resources from the Edith Nourse Rogers Memorial VA Hospital.

Conflict of interest

Dr. Kathuria has consulted for Remedy Partners on relevance of codes for pulmonary services. The authors have no other conflicts of interests to disclose.

Disclaimer

The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. The funding organizations had no role in the design and conduct of the study; the collection, management, analysis, and inter- pretation of the data; or the preparation, review, or approval of the manuscript.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https:// doi.org/10.1016/j.addbeh.2019.02.017.

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