However, most programs allowed tobacco use in designated outdoor areas, such as front or back porches, program parking lots, or other specified areas.Data collection was conducted by research staff during site visits in 2019. All adult clients enrolled in each program on site visit days were eligible to complete the survey.Research staff reviewed study information with clients in small groups. Those interested to participate were given an iPad with a pre-populated research ID number, reviewed the study information sheet on the iPad, and clicked “Agree” to complete an online Qualtrics™ survey. Informed consent was obtained from all individual participants included in the study. The self administered survey took approximately 30 minutes and participation was anonymous. Participants received a $20 gift card for study participation. Study procedures were approved by the institutional review board of the University of X. There were 682 clients enrolled in the participating programs at the time of the site visits and 562 completed the survey, giving an 82% participation rate. Current use of tobacco products was self-reported. Current cigarette smokers were those who reported having smoked ≥100 cigarettes during their lifetime and currently smoked at the time of survey. Current users of each of the other tobacco products were those who had reported using [e-cigarette, cigar/cigarillo,cannabis grow tent and smokeless tobacco during the past 30 days.There were 5 participants selecting “Don’t know” for current use of alternative tobacco products and their responses were coded as missing.
Based on their reports on use of four tobacco products, participants were categorized into one of three categories: poly tobacco users , dual tobacco users , and single tobacco users . Nicotine dependence was measured using the Heaviness of Smoking Index ,a 6- point scale based on two self-report items . The HSI has demonstrated reliability and validity as a measure of nicotine dependence severity, with internal consistency of 0.63,and the correlation with the Fagerstrom Test for Nicotine Dependence score of 0.94.Quitting experience was measured by two items. Having past-year quit attempts was assessed by the item “In the past year, did you quit smoking voluntarily for at least 24 hours?” Participants also reported whether they had ever used e-cigarettes to try to quit smoking. Intention to quit smoking was assessed by the item “Are you seriously thinking of quitting smoking?” with response options including “Yes, in the next 30 days”, “Yes, within the next six months but not in the next 30 days;” and “No”.Intention to quit smoking was defined as seriously thinking of quitting in the next 30 days . Past 30-day use of blunt or spliff was assessed by the item “Have you mixed tobacco and marijuana and smoked them together in the past 30 days?” Perceived physical and mental health assessments were based on the Centers for Disease Control and Prevention’s Healthy Days Measures.As defined by the CDC, the term “physically unhealthy days” was used to describe a number of days when physical health was not good, and was assessed by the item “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?” Likewise, the term “mentally unhealthy days” was used to describe a number of days when mental health was not good, and was assessed by the item “.
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Demographic characteristics included age, gender, race/ethnicity, and educational attainment. Age was self-reported. Gender was self-reported as male, female, transgender, gender queer, and other. Since there were 10 participants identifying as transgender and gender queer, these individuals were combined into the “Other” group. Race/ethnicity was measured by combining two items: race and ethnicity . Due to small numbers of Non-Hispanic Asian/Pacific Islander and American Indian/Alaskan Native participants , these subgroups were collapsed into “Other/Multi-race”, resulting in only four groups in the analysis . Educational attainment was measured as less than a high school education, high school or GED equivalent, and greater than a high school education. Participants were asked about reasons for entering treatment programs with answer options including treatment for SUD, for both SUD and a mental health condition, or for other reasons. Those with a SUD problem, or SUD and mental health problem, were asked about primary drug for treatment and/or mental health diagnosis, respectively. Persons reporting treatment for other reasons were most often referred by criminal justice sources. If they did not disclose a SUD or mental health reason for treatment, they were not asked for primary drug or mental health diagnoses. In addition, participants reported their time in treatment . Participant characteristics were summarized for the total sample and by tobacco use pattern . Since the outcome was a three category variable, we employed multi-nomial regression modeling with single tobacco use as the referent outcome and cluster–robust standard errors to account for clients nested within each treatment program.A multivariate model included all independent variables and controlled for demographic variables and time in treatment. The analysis used complete cases. Multi-collinearity among the independent variables was examined by Variance Inflation Factor and the results showed no presence of multi-collinearity. All tests were two-tailed with a significance level of α less than 0.05. Statistical analyses were performed using STATA version 15 .Table 2 describes tobacco use patterns among the total tobacco users and among each tobacco use subgroup. Of the total sample, 32.6% reported single tobacco use, 18.9% reported dual tobacco use, and 14.0% reported poly tobacco use. Most tobacco users were using cigarettes . Among the alternative tobacco products, e-cigarettes were the most commonly used in the past 30 days , followed by cigars/cigarillos , and smokeless tobacco .
Among tobacco users, the top three common patterns were exclusive cigarette use , dual use of cigarettes and e-cigarettes , and dual use of cigarettes and cigars/cigarillos . Compared to single tobacco users, dual and poly users had greater HIS scores and higher proportions of ever using e-cigarettes for quitting smoking and past 30-day use of blunts/spliffs. Using cross-sectional data from 562 clients in residential SUD treatment programs in California, we found that 65.5% of the sample were using any tobacco, with multiple tobacco use being equally prevalent as single tobacco use . Our estimate of multiple tobacco use is much higher than that in the general population 6,24 and also higher than the previous estimate from a national sample of people in SUD treatment.This study adds to current evidence identifying multiple tobacco use as an emerging public health issue among people in SUD treatment. Notably, our observation that proportion of dual users was higher than that of poly tobacco users has not been reported in previous research in SUD populations. In addition, consistent with previous studies among SUD samples,we found that e-cigarette was the most common alternative tobacco product used and dual use of cigarettes and e-cigarettes was the most common pattern of multiple tobacco use. However, our study is among the first bringing up the popularity of cigars/cigarillos and its dual use with cigarettes, calling for greater attention to this dual use pattern among people with SUD. This study extends existing literature by indicating factors associated with dual and poly tobacco use among people in SUD treatment. Current tobacco users who had ever used ecigarettes for quitting smoking were more likely to be both dual and poly tobacco users. In addition, among those who reported ever using e-cigarettes to quit smoking, 54% were still using e-cigarettes at the time of our survey . Although the efficacy of e-cigarettes as cessation aids is unclear,25 current evidence indicated that e-cigarette use was related to greatersmoking26 and the escalation of poly tobacco use over time,and thus,grow lights for cannabis may not be an effective aid for long-term cessation.Aligned with this evidence, our study suggested that current tobacco users in SUD treatment who are unsuccessful in quitting by using e-cigarettes may continue using multiple tobacco products. In our study, past 30-day use of blunt/spliff was strongly associated with poly tobacco use. Since use of cigars/cigarillos was prevalent in our sample, it is possible that participants were using cigars/cigarillos for blunt use. This finding may partly reflect our recruitment in California – a state having legalized recreational cannabis use since 2018 and considered the largest cannabis market in the US.Co-use of tobacco and cannabis is even higher than tobacco use alone among California’s young people.In the general population, cannabis use is associated with persistent cigarette smoking, high nicotine dependence, and low cessation among cigarette smokers.Likewise, a study among the SUD population found that ever users of blunt/spliff were less likely to plan to quit in the next 30 days.Given the increasing legalization of cannabis use in the US, our finding and other emerging evidence points to a need to address co-use of tobacco and cannabis and its potential impacts on tobacco use and cessation among people in SUD treatment.
Consistent with previous research among the general population and the SUD treatment population, we found that poly tobacco users had greater nicotine dependence and dual users had fewer days of good mental health as compared to single tobacco users. Mental health is frequently comorbid with SUD, and mental health problems is also linked to multiple tobacco use.This highlights a need to address the intersection of multiple tobacco use and mental health in SUD treatment programs. While prior studies in the SUD population found that multiple tobacco users were more likely to have past-year quit attempts,we did not find differences in having quit attempts and intention to quit smoking between dual or poly tobacco users and single tobacco users. More research is needed to better understand quitting intention, quit attempts, and cessation outcomes among dual and poly tobacco users in SUD treatment. Our study has implications for efforts to address tobacco use in the SUD population. As dual and poly tobacco use is highly prevalent among clients in SUD treatment and may confer additive risk compared to cigarette smoking alone, SUD treatment programs need to screen and assess the use of alternative tobacco products to better provide cessation supports for quitting cigarette smoking as well as quitting other types of tobacco use. Dual and poly tobacco users may comprise distinct groups, given that their use of multiple tobacco products is associated with greater nicotine dependence, co-use with cannabis in the form of blunt/spliff, and mental health problems, and thus, tailored interventions or multi-component interventions may be needed to address multiple health risks simultaneously. Particularly, interventions targeting dual use of cigarettes with e-cigarettes or cigars/cigarillos should be provided since they may place people in SUD treatment at risk for increased negative health effects and continued tobacco use rather than quitting.Although in-door smoking is prohibited in residential SUD treatment programs in California, clients may still smoke cigarettes and use other tobacco products outdoors. Tobacco free grounds policies, which ban use of tobacco products on treatment program grounds, should be adopted to reduce tobacco use among clients in SUD treatment.16 Study limitations include reliance on cross-sectional data, which precludes causal inference. Second, self-reported data in this study may have been susceptible to some degree of recall and social desirability bias. Third, the generalization of study findings is limited by the convenience sampling strategy, the inclusion of residential SUD programs only, and the fact that all programs were located in California. Finally, we could not explore reasons for dual and poly tobacco use patterns as well as context of using alternative tobacco products due to the small sample size and original measures. Future research should investigate mechanisms underlying tobacco use patterns among people in SUD treatment to find the best ways to treat tobacco use in this population. In conclusion, this study revealed high prevalence of dual and poly tobacco use among people in SUD treatment, and suggested that SUD treatment programs should address use of other tobacco products as well as cigarette smoking among their clients. In addition, interventions for dual and poly tobacco users should address use of e-cigarettes, cigars/cigarillos, and blunt/spliff as well as mental health to improve cessation outcomes and reduce tobacco related health disparities among this population.Cigarette smoking is strongly associated with alcohol use , and smoking is especially common among heavy drinkers and binge drinkers .