The protected addiction: exploring staff beliefs toward integrating tobacco dependence into substance abuse treatment services.
Employee incentives (Surveys)
Employee motivation (Health aspects)
Employee motivation (Surveys)
Pharmaceutical industry (Surveys)
Pharmaceutical industry (Health aspects)
Smoking cessation programs (Health aspects)
Smoking cessation programs (Surveys)
Tobacco industry (Surveys)
Tobacco industry (Health aspects)
Alcoholism (Care and treatment)
Alcoholism (Health aspects)
Substance abuse (Care and treatment)
Substance abuse (Health aspects)
Substance abuse (Surveys)
Hammond, Gretchen Clark
|Publication:||Name: Journal of Alcohol & Drug Education Publisher: American Alcohol & Drug Information Foundation Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Psychology and mental health; Social sciences Copyright: COPYRIGHT 2009 American Alcohol & Drug Information Foundation ISSN: 0090-1482|
|Issue:||Date: August, 2009 Source Volume: 53 Source Issue: 2|
|Product:||Product Code: 9911210 Motivational Techniques; 8000142 Antismoking Programs; 8000143 Alcohol & Drug Abuse Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 2833 Medicinals and botanicals; 2834 Pharmaceutical preparations; 8093 Specialty outpatient clinics, not elsewhere classified|
Survey research was used to explore the beliefs of 963 staff members regarding the myths to treating tobacco dependence and the integration of tobacco dependence into substance abuse treatment programs. The staff represented a mixture of residential, outpatient, and prevention-based gender-specific (women only) treatment centers throughout Ohio. The study found the following: a high percentage of staff believed in the conventional myths associated with the treatment of tobacco in chemically dependent persons; current smokers were reluctant to support all substance abuse treatment facilities in becoming tobacco-free, yet did support treating tobacco dependence in their facilities; and former and never smokers supported tobacco-free policies for their and all treatment facilities. Education and support for staff in treating tobacco dependence is recommended.
Tobacco use among chemically dependent persons is high with prevalence rates estimated at 70-90% compared to 21% in the current adult population in the United States (Batel, Pessione, Maitre, & Reuff, 1995; Centers for Disease Control and Prevention [CDC], 2007; Kalman, Morissete, & George, 2005; Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2002; Sharp, Schwartz, Nigthingale, & Novak, 2003). Despite such a high percentage of tobacco users among chemically dependent persons, substance abuse programs are slow to integrate tobacco dependence into existing treatment services (Fuller et al., 2007; Ziedonis, Guydish, Williams, Steinberg, & Foulds, 2006). This reluctance is often fueled by prevailing myths concerning concurrent treatment of alcohol, tobacco and other drugs as detrimental to treatment outcomes (Gulliver, Kamholz, & Helstrom, 2006). Substance abuse treatment staff are estimated to use tobacco at rates of 30-40% (Bemstein & Stoduto, 1999; Friend & Levy, 2004; Fuller et al., 2007). Staff resistance to the integration of tobacco into existing treatment services may be rooted in myth and dogma as well as in its own tobacco use. Substance abuse treatment facilities must address these underlying issues in order to gain staff support and cooperation for the integration and treatment of tobacco dependence. This study explores staff: (a) beliefs about existing myths around treating tobacco dependence; and (b) beliefs toward integrating tobacco dependence into its substance abuse treatment programs.
Treating Tobacco Dependence: Prevailing Myths
Treatment for tobacco is often ignored or omitted within the standard substance abuse treatment model, which is fueled by several myths designed to discredit the needs for and benefits of addressing this addiction (Fuller et al., 2007; Ziedonis et al., 2006). The prevailing myths commonly discussed include the following: (a) Chemically dependent clients do not want to quit using tobacco (Kalman, 1998; Kodl, Fu, & Joseph, 2006); (b) concurrent treatment will bring detrimental consequences to recovery outcomes (Bowman & Walsh, 2003; Joseph, Willenbring, Nugent, & Nelson, 2004; Kalman, 1998); (c) tobacco is more benign than other substances (Gulliver et al., 2006); and (d) addressing tobacco dependence would be too stressful for the client (Ziedonis et al., 2006). Studies on the treatment of tobacco dependence refute such myths and create stronger evidence for the treatment of tobacco dependence with chemically dependent individuals.
Numerous studies have found that clients receiving substance abuse treatment desire to quit using tobacco and are interested in receiving treatment for their tobacco dependence either during or after substance abuse treatment (Bernstein & Stoduto, 1999; Bobo, Lando, Walker, & McIlvain, 1996; Burling, Burling, & Latini, 2001; Clarke, Stein, McGarry, & Gogineni, 2001; Ellingstad, Sobell, Sobell, Cleland, & Agrawal, 1999; Joseph, Lexau, Willenbring, Nugent, & Nelson, 2004; Zullino, Besson, & Schnyder, 2000). Bernstein & Studuto (1999) found that when implementing an optional educational smoking program at an abstinence-based addiction treatment center, 55.6% of staff and 38% of clients who smoked agreed to participate, and 17.5% of clients were abstinent at the 12-month follow-up. Bobo et al. (1996) found that 27.7% of recovering alcoholics made a serious quit attempt within six months of discharge and Kohn, Tsoh and Weisner (2003) found that 13% of smokers in a substance abuse treatment program quit using tobacco when assessed at a 12-month follow-up study without receiving formal tobacco dependence treatment. These studies refute this myth and demonstrate that many tobacco dependent clients would like to quit using tobacco and do make serious quit attempts on their own.
Treating chemically dependent individuals concurrently for tobacco dependence is often believed to interfere with recovery outcomes; yet research has continually found that failure to quit smoking may lead to worse treatment outcomes and may actually jeopardize sobriety (Bobo, McIlvain, Lando, Walker, & Leed-Kelly, 1998; Frosch, Shoptaw, Nahom, & Jarvik, 2000; Hurt, Eberman, & Croghan, 1994; Joseph, Willenbring et al., 2004; Kohn et al., 2003; Lemon, Friedman, & Stein, 2002; Toneatoo, Sobell, & Sobell, 1995). Kohn et al. (2003) found that, at a 12-month follow-up, 69.8% of men and women who quit using tobacco while in substance abuse treatment and 62.9% of nonsmokers were significantly (p<.05) more likely to report abstinence from alcohol and non-nicotine drugs, for the past 30 days when compared to smokers (52.3%); and individuals who started or resumed smoking after substance abuse treatment (56.7%). Lemon et al. (2003) found smoking cessation was associated with greater abstinence from other drugs post substance abuse treatment. Prochaska, Delucchi, & Hall (2004) conducted a meta-analysis of smoking cessation intervention outcomes from 19 randomized controlled trials and found that smoking cessation programs provided during substance abuse treatment were associated with a 25% increased likelihood of long-term abstinence for clients from alcohol or other drugs compared to those persons in substance abuse treatment facilities that did not receive smoking cessation programs. This research refutes the myth surrounding poorer outcomes and demonstrates the necessity to address tobacco dependence in substance abuse treatment facilities.
The belief that tobacco is a more benign substance versus other drugs of addiction is based on arguments that overlook social and health consequences. In actuality, tobacco use is the leading cause of preventable death in the United States and causes more deaths than alcohol, cocaine, crack, heroin, homicide, suicide, human immunodeficiency virus (HIV) and motor vehicle accidents combined (CDC, 2007; U.S. Department of Health and Human Services [HHS], 2006). Although the short term effects of non-tobacco chemicals appear more dangerous (Gulliver et al., 2006), chemically dependent individuals are more likely to die from tobacco-related diseases than from the use of non-tobacco chemicals (Hurt, Eberman, Slade & Karan, 1993; Hurt et al., 1996). Non-tobacco chemicals do pose threats to the health of substance abuse treatment clients, yet tobacco appears to exacerbate these threats and is more likely to harm the client with continued use (York & Hirsch, 1995). Bein and Burge (1990) note the synergistic effect of tobacco and other drug uses are estimated to be 50% greater than either used alone, further complicating the physical health consequences of poly-substance use. Prochaska et al. (2004) highlight the power of the implicit message found in the exclusion of tobacco from treatment: quitting tobacco is "not a priority for recovery or health" (p. 1154). Therefore, when considering the health of the client, tobacco is a drug that should not be ignored.
Concurrent treatment for alcohol, tobacco and other drugs is perceived as too stressful for clients (Rohsenow, Colby, Martin, & Monti, 2005; Ziedonis et al., 2006); therefore, clients are often encouraged to tackle their tobacco addiction at a later time. This approach to tobacco dependence is counter to what is often expressed in abstinent-based substance abuse treatment programs where clients are required to "quit all drugs at one time." For example, individuals addicted to cocaine are not permitted to use marijuana or alcohol while receiving treatment or encouraged to use these substances once they leave treatment. A menu-like approach to addiction where one may pick-and-choose which drugs he or she would like to abstain from is generally not taken, except in the case of tobacco. Therefore, excluding tobacco from this list of restricted chemicals is contradictory to the overall message of abstinence. As was noted above, concurrent treatment for tobacco and other drugs is not detrimental (Reid et al., 2008) and has been found to improve treatment outcomes and increase sobriety rates post treatment (Frosch et al., 2000; Kohn et al., 2003; Lemon et al., 2002; Prochaska et al., 2004). The evidence suggests that not including tobacco dependence in treatment could actually cause more stress to the client by acting as a trigger for other substances (Williams et al., 2005; Ziedonis et al., 2006).
Treating Tobacco Dependence." Staff Influence
Staff members play a crucial role in the recovery process for persons in substance abuse treatment and their attitudes and actions will influence the treatment of tobacco dependence. Acknowledgement of the deleterious nature of tobacco and the addictive properties associated with its use are the first steps toward integration in substance abuse treatment. Gaining the support of all staff members may prove difficult as their own addictions to tobacco may cloud their opinions on the treatment of tobacco dependence. Further, when the existing culture is tailored to the needs of smoking clients including smoke breaks, budgeting for tobacco purchases or tobacco as a treatment reward, staff may view the task of treating tobacco as too daunting. These factors surrounding tobacco offer it a protected status in many substance abuse treatment facilities.
Substance abuse treatment staff members are often reluctant to talk with clients about tobacco cessation (Friend & Levy, 2004), and those members who smoke are more likely to be resistant to the treatment of clients for tobacco dependence (Bobo, Slade, & Hoffman, 1995; Fuller et al., 2007; Hahn, Warnick & Plemmons, 1999). Approximately 30-40% of substance abuse treatment staff use tobacco (Bernstein & Stoduto, 1999) and these staff members are least likely to encourage chemically dependent clients from quitting (Ziedonis et al., 2006). In order to move the substance abuse treatment field toward the integration of tobacco dependence into existing treatment programs, the beliefs of staff in regard to treating tobacco should be assessed as well as their beliefs in the myths against treating tobacco. Assessing the beliefs of staff can help identify gaps in support for the treatment for tobacco dependence and can provide the baseline for staff education on this protected addiction.
This survey research study explored the beliefs of staff regarding the integration of tobacco dependence into substance abuse treatment programs and the myths regarding tobacco dependence treatment. Additionally, this study assessed the readiness of tobacco-dependent staff members to address their own addictions.
This study was administered by the Ohio Women's Coalition Smoking Cessation and Prevention Initiative (OWCSC&PI), which was funded by the Ohio Tobacco Prevention Foundation (OTPF). The OWCSC&PI was administered by Amethyst, Inc, a gender-specific (women only) treatment center in Columbus, Ohio, and served to provide training and technical assistance to organizations interested in treating tobacco. Although the OWCSC&PI worked primarily with gender-specific substance abuse treatment programs, the program provided services to mental health treatment facilities, health care and educational organizations. The OWCSC&PI conducted this study in order to better align its training initiatives with the needs of the targeted gender-specific treatment facilities.
This descriptive study consisted of survey research in which a 21-item questionnaire was sent to the 73 certified gender-specific substance abuse treatment facilities in Ohio. The survey instructions asked for distribution to staff members including members of management, direct service staff, and non-direct service staff. The completion of the questionnaire was voluntary and was strictly confidential. An initial questionnaire, and a follow-up questionnaire to those who had not responded initially, yielded a total of 994 questionnaires from 54 substance abuse treatment facilities; 2 agencies had incorporated tobacco-free policies at the agency and were therefore not included in the analysis leaving 963 questionnaires from 52 substance abuse treatment facilities.
The questionnaire was developed by the OWCSC&PI staff and consisted of demographic information (age, gender), opinion questions and knowledge assessment of tobacco dependence. Current and never smokers were determined by the questions, "Do you currently use tobacco product?" (yes or no). Information on use and cessation history was gathered including age of onset, quit attempts, length of abstinence, and methods utilized for quitting. Questions on amount of type of tobacco use were not in this survey. Persons who answered "no" to being a current smoker, because they either never used or formerly used, provided detail on their quit history indicating how long the former users had remained abstinent.
A question that mirrored the Stages of Change was used in order to assess the readiness of staff to address its own addiction (Prochaska & DiClemente, 1984; Prochaska, DiClemente, & Norcross, 1992). The Stages of Change is an element of the Transtheoretical Model (TTM) that assesses an individual's readiness to make a behavioral change and theorizes that individuals tend to move, not necessarily in a linear fashion, through five stages: precontemplation, contemplation, preparation, action, maintenance. Current stage of change was assessed by asking smokers and former smokers "do you want to quit using tobacco?" and were given the following possible responses: (a) I am not considering quitting in the next six months (precontemplation); (b) I am considering quitting within the next six months (contemplation); (c) I am planning to quit within the next thirty days (preparation); (d) I have quit within the past six months (action); and (e) I have not smoked within the past six months (maintenance) (Prochaska et al., 1992).
Opinion and knowledge assessment questions were based on conventional beliefs and myths about tobacco use and cessation for chemically dependent persons as demonstrated through the research listed in the literature review. The staff members' opinions toward treating tobacco dependence were assessed by asking staff to respond either agree, disagree, or no opinion to the following statements: (a) All alcohol and other drug (AOD) treatment facilities should be tobacco-free; (b) I think this agency should treat nicotine dependence; and (c) I think this agency should be tobacco-free. The staff members' beliefs in the myths towards treating tobacco dependence were assessed by asking the staff to respond either agree, disagree, or no opinion to the following statements: (a) Recovering alcoholics/addicts can quit smoking without endangering their sobriety; (b) quitting smoking would interfere with recovery from other drugs; (c) stopping tobacco use adds unnecessary stress to individuals in the midst of treatment; (d) a successful tobacco cessation program requires that staff be tobacco-free; and (e) there is evidence that stopping tobacco use enhances alcohol and drug abstinence rates.
Crosstabulations were employed to determine the percentage of current, former and never smokers in regard to age and gender, and to determine the percentage of current and former smokers in regard to age at smoking initiation, number of past quit attempts, length of abstinence, and methods used to quit smoking. Chi-square tests of independence were conducted to determine any significant differences between the characteristics across the three groups (current, former and never smokers) with statistical significance set at a .05 level. Crosstabulations were employed to determine the frequencies and percentages of current, former, and never smokers that responded either agree, disagree or no opinion to the questions addressing staff members' beliefs towards treating tobacco dependence; and chi-square tests of independence were performed to examine the relationship between smoking status (current, former, and never smokers) and level of agreement to the statements (agree, disagree, or no opinion). Statistical significance was set at a .05 level.
In regard to the agencies that were represented in this study, 50% were outpatient, 36.5% were residential, and 13.5% were prevention. The 19 agencies that did not respond consisted of 42.1% from residential, 36.8% from outpatient, and 21.1% from prevention. Over 20% of the respondents were male (N= 152) and 79.8% were female (N=601). Over 26% identified as a current smoker (N=250), 48.7% as a former smoker (N=465), and 25.1% as a nonsmoker (N=240). For stage of change, 35.9% of current smokers reported being in the precontemplation stage, 43.3% in the contemplation stage, 18.0% in the preparation stage, and 2.4% in the action stage. Table 1 reveals the characteristics by current smokers, former smokers, and never smokers. Nearly 60% of current smokers and 64.4% of former smokers reported having made between 1-3 quit attempts, and 24.9% of current smokers and 93.4% of former smokers reported having a length of abstinence that was greater than one year. The most common method used to quit smoking was "just quit" for current smokers (42.5%) and former smokers (61.3%) with only 13.6% of smokers and 5.5% of former smokers using Nicotine Replacement Therapy (NRT) to assist with their quit attempt.
Table 2 reports the frequencies and percentages of level of agreement of current smokers, former smokers, and never smokers for each statement. The majority of current, former and never smokers agreed that recovering alcoholics/addicts can quit smoking without endangering their sobriety, and disagreed that quitting smoking would interfere with recovery from other drugs. There were no statistical differences among the groups. The majority of never smokers disagreed that stopping tobacco use adds unnecessary stress; yet the majority of current smokers and former smokers agreed ([chi square] (4, N = 923) = 47.81, p<.01). When answering whether successful tobacco cessation programs require staff to be tobacco-free, the majority of current smokers disagreed compared to the majority of former smokers and never smokers who agreed ([chi square] (4, N = 907) = 62.01, p<.01). The majority of current smokers disagreed that abstinence rates are enhanced when stopping tobacco compared to a minority of former smokers and never smokers who disagreed ([chi square] (4, N = 894) = 46.67, p<.01).
In regard to attitudes towards treating tobacco dependence, the majority of current smokers disagreed that all AOD treatment facilities should be tobacco-free compared to the majority of former smokers and never smokers who agreed ([chi square] (4, N = 919) = 1.35E2, p<.01). The majority of current, former and never smokers agreed that their agency should treat tobacco dependence ([chi square] (4, N = 915) = 28.22, p<.01); yet the level of agreement to whether the agency should be tobacco-free reveals that the majority of current smokers disagreed compared to the majority of former smokers and never smokers who agreed ([chi square] (4, N = 920) = 1.95E2, p<.01).
This study has explored substance-abuse treatment staffs' beliefs in the prevailing myths about treating tobacco dependence in substance abuse treatment centers (Bowman & Walsh, 2003; Gulliver et al., 2006; Joseph, Willenbring et al., 2004; Kalman, 1998; Kodl et al., 2006; Ziedonis et al., 2006). The results of this study show a mixture in beliefs about the treatment of tobacco dependence, particularly by smoking status, and point to either a lack of knowledge or acceptance for treating tobacco dependence from some staff members as it relates to overall sobriety from alcohol and other drugs. The findings indicate a need for staff education on the synergistic effects of poly-substance use, which includes tobacco. Staff education administered at the agency or system level should provide a review of the evidence supporting the treatment of tobacco dependence concurrently with treatment for other substances (Ziedonis, et al., 2006).
The current smoking status of staff and level of staff support are two critical factors to consider when moving towards incorporating tobacco dependence into treatment or a tobacco-free policy in an organization. The support of all staff is often necessary for a treatment program to be successful so that the message for treatment of tobacco is consistent (Fuller et al., 2007; Ziedonis et al., 2006). This study found that 26.2% of staff members were current smokers, 48.7% were former smokers and 25.1% were nonsmokers, which supports prior research indicating that staff members of substance abuse treatment programs smoke at a higher rate compared to the adult population (Bobo et al., 1995; Friend & Levy, 2004; Fuller et al., 2007). With over a quarter of staff members claiming to use tobacco, treatment facilities must engage these staff members as they will have to address their own tobacco use while simultaneously assisting clients.
The majority of current tobacco users in this study considered themselves in the contemplation or preparation stage indicating their readiness to address their tobacco use and make a quit attempt within six months or less. Treatment facilities can provide extra support to these smoking staff members through a variety of emotional, social and monetary means, such as assisting with the payment for individual or group counseling, nicotine replacement therapy (NRT), hypnotherapy or other treatments. Educational activities, smoke-out days or work-based support sessions, and tobacco cessation groups provide a means to foster discussion and encourage persons in their quit processes.
Treatment facilities may encounter reluctance from current smokers to treating tobacco dependence or supporting tobacco-free policies due to their own tobacco use. Although the findings from this study revealed that the largest percentage of current, former and never smokers agreed that their agencies should treat tobacco dependence, the majority of current smokers were reluctant to move their agencies and all substance abuse programs towards incorporating tobacco-free policies. Treating tobacco dependence enables clients to receive treatment; yet an agency-wide tobacco-free policy would require the smoking staff to address its own tobacco use likely through the incorporation of tobacco into a drug-free workplace policy. Alternatively, the majority of former smokers and nonsmokers were supportive of incorporating a tobacco-free policy at their agency. These results further demonstrate the necessity for staff training on the evidence supporting treating tobacco dependence and on addressing current smoking staff members' own concerns and fears about treating their tobacco use through emotional, social or monetary measures.
The findings of this study should be interpreted against several limitations. First, the questionnaires provide data that are based on staff self-report and the answers cannot be verified. Second, this study had to incorporate a convenience sample as the current data from the state do not indicate the number of persons employed throughout Ohio's publicly-funded treatment system leaving the number of non-respondents unknown. Last, the results from this study represent the staff members from abstinence-based, gender-specific substance abuse treatment facilities across Ohio, as this was the target population for the OWCSC&PI. Future research should be conducted with staff members of other types of treatment facilities to determine any differences in staff members' beliefs towards treating tobacco dependence. Despite the limitations, this study provides further insight into the beliefs and attitudes of staff from substance abuse treatment facilities.
This study has reviewed the evidence supporting the treating of tobacco dependence concurrently with other chemical dependencies and the influence of staff members on treating tobacco dependence. The findings from this study highlight a continued belief in myths surrounding treating tobacco dependence, particularly by current smokers, reluctance for all substance abuse facilities to move towards a tobacco-free policy, yet a general support for treating tobacco dependence within their facilities. In order to move forward with the treatment of tobacco dependence in substance abuse treatment, facilities must educate staff to the evidence supporting this treatment and support staff members who are reluctant to make the change, particularly as it influences their tobacco use.
Correspondence concerning this article should be addressed to: Barbra Teater, Ph.D., Department of Social & Policy Sciences, University of Bath, Bath, BA2 7AY, UK, email: firstname.lastname@example.org
The authors confirm that this manuscript has not been submitted simultaneously to any other journal.
Prepared under Grant number 03-0076 from the Ohio Tobacco Prevention Foundation (OTPF) granted to Amethyst, Inc. Points of view or opinions in this document are those of the authors and do not necessarily represent the official position of the Ohio Tobacco Prevention Foundation.
An earlier version of this paper was presented as a poster at the World Conference on Tobacco OR Health, Washington, DC, USA, July, 2006.
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Barbra Teater, Ph.D.
University of Bath
Gretchen Clark Hammond, MSW, LSW, TTS
TABLE 1: Characteristics by Current Smokers, Former Smokers, and Nonsmokers Current Former Never (N = 250) (N = 465) (N = 240) Variable (N) Smokers Smokers Smokers Age (939) 15-25 7.0% 6.1% 10.1% ** 26-36 15.6% 21.4% 31.9% 37-45 26.2% 20.8% 16.0% 46-55 34.8% 32.8% 26.5% [greater than 16.4% 18.4% 15.2% or equal to] 56 Gender (749) Male 23.8% 20.7% 14.8% female 76.2% 79.3% 85.2% Age at Smoking Initiation (655) <10-12 17.6% 15.8% -- 13-15 27.6% 27.7% -- 16-18 33.2% 27.7% -- [greater than 21.6% 28.8% -- or equal to] 19 Number of Past Quit Attempts (630) 0 18.5% 13.6% -- 1-3 59.3% 64.4% -- [greater than 22.2% 22.0% -- or equal to] 4 Length of Abstinence (629) <1-30 days 39.3% 0.5% ** -- 1-5 months 19.8% 2.0% -- 6-1l months 16.0% 4.1% -- [greater than 24.9% 93.4% -- or equal to] 1 year Methods Used to Quit (619) Just Quit 42.5% 61.3% ** -- NRT 13.6% 5.5% -- Other 14.5% 13.8% -- Multiple 29.4% 19.4% -- ** p <. 01 Note: Age at smoking initiation, number of past quit attempts, length of abstinence, and methods used to quit only apply to current smokers and former smokers. TABLE 2: Crosstabulations Assessing Staff Members 'Beliefs and Readiness to Treat Tobacco Dependence Current Former Never Statement Smokers Smokers Smokers 1. Recovering alcoholics/addicts can quit smoking without endangering their sobriety. (N=917) Agree 47.3% (113) 53.2% (238) 51.1% (118) Disagree 24.7% (59) 21.5% (96) 19.9% (46) No Opinion 28.0% (67) 25.3% (113) 29.0% (67) 2. Quitting smoking would interfere with recovery from other drugs. (N = 914) Agree 20.7% (49) 18.5% (82) 20.5% (48) Disagree Sl.l%(121) 57.3%(254) 54.7%(128) No Opinion 28.3% (67) 24.2% (107) 24.8% (58) 3. Stopping tobacco use adds unnecessary stress to individuals in the midst of treatment. (N = 923) Agree 58.8% (141) 40.6% (183) 31.0% (72) ** Disagree 17.1% (41) 36.1% (163) 39.2% (91) No Opinion 24.2% (58) 23.3% (105) 29.7% (69) 4. A successful tobacco cessation program requires that staff be tobacco-free. (N = 907) Agree 34.9% (80) 57.3% (255) 66.5% (155) ** Disagree 41.5% (95) 21.3% (95) 14.6% (34) No Opinion 23.6% (54) 21.3% (95) 18.9% (44) 5. There is evidence that stopping tobacco use enhances alcohol and drug abstinence rates. (N = 894) Agree 25.1% (58) 41.8% (183) 37.3% (84) ** Disagree 38.5% (89) 18.0% (79) 16.9% (38) No Opinion 36.4% (84) 40.2% (176) 45.8% (103) 6. All AOD treatment facilities should be tobacco-free. (N = 919) Agree 18.6% (44) 51.6% (232) 61.6% (143) ** Disagree 59.9% (142) 24.7% (111) 18.1 % (42) No Opinion 21.5% (51) 23.8% (107) 20.3% (47) 7. I think this agency should treat nicotine dependence. (N = 915) Agree 44.7% (105) 61.0% (274) 65.8% (152) ** Disagree 28.1% (66) 16.3% (73) 13.9% (32) No Opinion 27.2% (64) 22.7% (102) 20.3% (47) 8. I think that this agency should be tobacco-free. (N=920) Agree 21.7% (51) 61.6% (278) 71.4% (167) ** Disagree 62.1% (146) 18.8% (85) 12.4% (29) No Opinion 62.1% (38) 19.5% (88) 16.3% (38) ** p <.0
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