Primary Report of First National Study on Merging Smoking Cessation with Drug Abuse Treatment in Welfare Organization, Iran 2017-Juniper publishers
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Abstract
Background: Tobacco smoking is very common in
drug abusers and here is a challenge to accept that smoking cessation
can be added to treatment for it. The aim of this study was to present
efficacy of merging smoking cessation with drug abuse treatment
nationally.
Method: This was a cross sectional study of
merging quit smoking intervention with behavioral therapy and medication
in 24 drug abuse treatment centers at welfare organization in 6
districts of Iran in 2017.
Results: More than 2000 male clients were
involved with age over 18. 78 % of them were satisfied with this new
treatment and after 6 months 23 % of them quit smoking, in 46 % smoking
less than half amount at first was seen and 31 % were smoker while they
had their maintenance medication on addiction.
Conclusion: Smoking cessation intervention was acceptable and can have a significant impact on the general health of drug abusers.
Background
Nicotine addiction is rarely regarded with the same urgency as drug narcotics abuse in the scope of public health [1].
Yet, with the rise of cigarette consumption within developing countries
reaching epidemic levels, the specter of widespread smoking- related
morbidity and mortality remains a looming public health crisis [2].
It is predicted that by 2030 over 80% of smoking- related deaths
worldwide will occur in countries with low or average income [3]. In the Islamic Republic of Iran, conservative estimates place the over prevalence at 16% [4].
Recent data show that 80.6% of current smokers first experimented
before the age of 15 years (around the average age of narcotics
experimentation). It is estimated that 10.3% of young people smoke
habitually [5].
Over the past two decades the demographics of drug
abuse in the Islamic Republic of Iran have been similarly changing.
Whereas the average age of addiction used to fall between 25 and 29
years, that figure is now between 10 and 19 years [6].
Today, the average drug abuser is younger and less financially stable.
Couple this trend with an over all younger population in the Islamic
Republic of Iran and the number of drug abusers regularly problematic
for Iranian health officials. Tobacco usage is very common among those
addicted to drugs and especially among opiate abusers, who constitute
the majority of the Islamic Republic of Iran's addict population. Among
this group 60%- 90 % are smokers [7].
The phenomenon of dual addictions has been noted in
studies around the world. In a study conducted in the northeastern
United States of America, 83 % of those who receive methadone treatment
are also addicted to smoking cigarettes [8].
Data from China's National Institute of Addiction show that cigarette
smoking is prevalent among an astounding 99.4 % of opiate addicts [9].
The principle explanation for the high prevalence of nicotine addiction
among opium addicts is the neurochemical relatedness of the addictions.
Research has shown that nicotine addiction is controlled by the same
chemical nerve receptors that control addiction to opium derivatives [10].
Those undergoing methadone treatment report an intensified craving for nicotine [11]. Stein et al. [12,13]
conducted a series of experiments in 2006 and 2007 that suggest there
is a significant relationship between nicotine replacement therapy and a
reduction in both smoking and drug abuse. Reid et al. [14] demonstrated that smoking cessation treatment can be added to treatment for drug abuse. Elkader et al. [15]
showed that those who quit smoking cigarettes become more jovial and
less restless or depressed and suggested that the two treatments can be
combined. Contrarily, West et al. [16]
noted that many treatment personnel will fully tolerate nicotine
addiction among their patients as they see smoking as a coping mechanism
for patients struggling with cravings for heroin and other hard drugs.
Nonetheless, it is clear that the elimination of
nicotine dependency is crucial for the successful treatment of drug
addiction. Doctors, clinicians and public health experts should become
aware of the relationship between addiction to nicotine and opium
derivatives in order to better provide for the social costs of public
health. For the first time in Iran Heydari et al. [17]
showed that smoking cessation treatment with opium maintenance therapy
had better outcome with less relapse. In 2014 following the confirmation
of this method in State Welfare Organization it was appointed to sign
scientific memorandum of understanding between Treatment Deputy of State
Welfare Organization and Tobacco Prevention and Control Research Center
of Shahid Beheshti Medical Sciences University.
It was also appointed to prepare common guidelines in
order to provide the ground for running treatment programs. Then in
2015 it was appointed in the first phase to choose seven provinces for
necessary trainings and starting to give smoking cessation services in
substance abuse treatment centers. The aim of this study was to present
efficacy of merging smoking cessation with drug abuse treatment
nationally.
Method
This was a cross-sectional study was done from 2015 to 2016. The results of previous clinical trial [17]
were reported to Iran Drug Control Headquarters and Treatment Deputy of
State Welfare Organization. However, due to the contradiction of these
results to the health policies at that time several scientific and
advisory meetings were held in these organizations during which similar
foreign and updated documents were presented and the treatment method
was defended. After having a memorandum in 2015 it was appointed in the
first phase to choose seven provinces of Tehran, Eastern Azerbayjan,
Razavi Khorasan, Isfahan, Fars and Mazandaran for necessary trainings
and starting to give smoking cessation services in substance abuse
treatment centers. From each province four centers were chosen including
two outpatient centers and two inpatient centers. Besides, 24 persons
including both physicians and health care workers were chosen to take
the related training courses and treatment guidelines.
These centers have provided the services since the
beginning of June 2016 and all the new clients of substance abuse
treatment were entered the survey. Clients with substance abuse
treatment were entered the survey. Clients with severe psychotic
disorders and having no family and specific address were omitted. All
services were given free of charge including visit, assessment of
tobacco smoking and its history, behavioral consultation and guidance to
use nicotinic and non-nicotinic medications. Of course the State
Welfare Organization dedicated some financial aids to these centers.
Findings
2086 persons entered the study. All the participants
were male. Their age average was 36.38±13.21 years. 1,213 person
(58.14%) consumed opium; 618 persons (29.6%) consumed amphetamine; and
the rest consumed more than one substance. All of them had the
experience of tobacco smoking. 1627 persons (78%) wanted to have
simultaneous smoking cessation and they were satisfied. Among them 375
persons (23%) could successfully quit smoking after six months and they
were also in the procedure of substance abuse maintenance treatment. For
748 persons (46%) the harm reduction was about the reduction of tobacco
smoking in half the amount of starting the study. But the smoking
cessation was not achieved in 504 persons (31%). All the colleagues in
24 centers were satisfied with this program and considered it as a
fruitful program.
Discussion
Our experience herein was merging smoking cessation
course with the State Welfare's program which was happening for the
first time across the nation. This study showed that patients and their
families were satisfied of simultaneous cessation of smoking and opium
and also it caused some reduction in substance abuse and relapse.
Since many studies have showed that [18,19]
in maintenance treatment of substance abuse, smoking cessation could
reduce the relapse rate of substance abuse and also it could promote the
quality of life, so it is essential to employ this method. However, it
wasn't taken seriously before the study of Heydari et al. [17]
and there was misbelieve that it was hard to take the cessation
programs of smoking and substance abuse parallel during the same period.
It is exactly the same matter that was pointed out in Shop taw study [20]
in which many families believed that substance abuse quit was highly
important and they accepted the consumption of tobacco products. Even
the addiction therapists believed that their duty was just in realm of
substance abuse and it was not about the whole realm of health. This
belief was reported in the studies of Tacke [21] & Baca [22].
In these circumstances the outcomes of study of Heydari et al. [17]
brought about a new challenge to alter the quit addiction programs. Due
to the outcomes of this study which showed that health care workers
were satisfied of simultaneous cessation of smoking and drug abuse and
also it caused some reduction in substance abuse and relapse, policy
makers of addiction treatment were convinced of changing the programs.
The exemplars of this experience are shown in the studies of Satre et
al. [23] & Josef et al. [24].
In our experience, about 40% of substance abusers
could reduce smoking to half the initial consumption. This trend is
totally plausible because as seen in the studies of Reid et al. [25] & Myers & Brown [26]
this phase could be beneficial for the patients' health and it made
them ready for the next phase. As it is seen in several studies [27,28]
simultaneous smoking cessation with drug abuse treatment not only leads
to negative consequences, but also it can be suggested for successful
treatment of drug abuse. Besides, as it is demonstrated in the present
study, this program can be generalized and developed in other provinces
all across the nation.
Many documents in Iran show that tobacco control program are acceptable [29-31] and many smoking cessation methods are available [32-38]
but this experience about merging smoking cessation with drug abuse
treatment is newly coming and may have effective outcomes in future. In
conclusion smoking cessation intervention was acceptable and can have a
significant impact on the general health of drug abusers.
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