Measuring smoking knowledge, attitudes and services (S-KAS) among clients in addiction treatment

Abstract

Background

Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings.

Method

250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure.

Results

Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two “service” factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach's alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82.

Conclusions

The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation.

Introduction

Currently over one billion persons smoke worldwide, and over 5 million deaths annually are attributed to tobacco (World Health Organization, 2010). In the United States (U.S.) tobacco control efforts have reduced smoking prevalence from 40% in 1964 to 20.6% currently (Centers for Disease Control and Prevention, 2009, Department of Health Education and Welfare, 1964). However, smoking remains prevalent among persons with alcohol and drug use disorders, and epidemiologic studies report smoking rates for these groups at 34% and 52%, respectively (Grant et al., 2004). Among persons in addiction treatment smoking prevalence ranges from 49 to 98% (Schroeder, 2009). This is true in the U.S., and in many countries where smoking rates have been reported for addiction treatment samples (Amit et al., 2003, Ellingstad et al., 1999, Gossop et al., 2007, Lawal et al., 1998, Nakamura et al., 2003). As one approach to elevated smoking rates, researchers in a number of countries have explored tobacco-related knowledge, attitudes and practices among clinicians (Ceraso et al., 2009, Walsh et al., 2005, Gokirmak et al., 2010).

In the context of high smoking rates in addiction treatment, three studies have concluded that tobacco dependence services are not provided in most U.S. addiction treatment programs (Friedmann et al., 2008, Fuller et al., 2007, Richter et al., 2004). Among program staff, tobacco-related knowledge and attitudes are barriers to providing tobacco services (Guydish et al., 2007). For example, smoking may be viewed by counselors as a low priority when compared to more immediate harms of other drug use, and staff may believe their patients are not interested in quitting (Hahn et al., 1999, Sees and Clark, 1993). Client attitudes may also affect tobacco services. Clients in one program were concerned that quitting smoking would create nicotine withdrawal symptoms and remove smoking as a coping strategy (Asher et al., 2003). Among clients entering a smoke-free rehabilitation facility, over half thought that smoking should not be addressed along with other addictions (Patten et al., 1999). Efforts to provide tobacco dependence interventions in addiction treatment must address staff and client attitudes about tobacco, while increasing access to tobacco-related services.

Several initiatives address tobacco dependence in addiction treatment. Veteran Affairs Medical Centers initiated practice guidelines for smoking cessation among all patients, including those in specialty addiction clinics (Sherman, 2008). New Jersey licensure standards encouraged all residential treatment programs to adopt smoke-free grounds (Williams et al., 2005), and New York recently required treatment programs to have smoke-free grounds and treat tobacco dependence for all clients on request (Tobacco-Free Services, 2008). Indiana initiated partnerships to support tobacco-free addiction treatment (Indiana Tobacco Prevention and Cessation, 2010), and other states have announced plans to adopt smoke-free grounds in their treatment systems (Oregon Department of Human Services, 2010, Utah Division of Substance Abuse and Mental Health, n.d.).

As such strategies are implemented, treatment programs may measure how those strategies affect client knowledge or attitudes related to tobacco, or whether such policies increase tobacco services. A number of studies have used client surveys for this purpose (Bernstein and Stoduto, 1999, Perine and Schare, 1999, Trudeau et al., 1995), with findings reported for individual survey items. For example, Joseph et al. (2004) used a client survey as one in a number of policy outcome measures, and reported on whether patients were counseled to quit smoking at their last clinic visit. To evaluate the New Jersey policy, Williams et al. (2005) reported on whether clients thought the policy was helpful.

Multi-item scales offer an alternative to individual items, giving comparability across studies, more stable estimates of underlying constructs, and known psychometric properties (Allen and Yen, 1979). The barriers to quitting smoking in substance abuse treatment (BQS-SAT) assesses whether respondents think that quitting smoking would lead to nicotine withdrawal symptoms or urges to use other drugs (Asher et al., 2003). The nicotine and other substance interaction expectancies questionnaire (NOSIE; Rohsenow et al., 2005) measures expectancies concerning the effects of smoking on addiction recovery. These measures are tailored to addiction treatment samples, but do not measure knowledge of the hazards of smoking, or tobacco services clients may receive while in treatment.

Delucchi et al. (2009) reported on a staff survey with scales assessing smoking-related knowledge, attitudes and practices (S-KAP). This paper reports on a similar survey of smoking-related knowledge, attitudes and services (S-KAS) among clients. The S-KAS may be useful to addiction treatment programs, or county, state or regional treatment systems, who want to assess whether their tobacco strategies are associated with changes in client knowledge or attitudes, or with tobacco services clients receive. The S-KAS is not a measure of client smoking cessation outcomes. It is designed to measure conditions that support clients in quitting smoking: knowledge of the hazards of smoking, attitudes about treating smoking in the program where they are enrolled, and tobacco-related services they receive.