Tobacco cessation and its current approach in substance use treatment programs was broadly discussed among focus groups. Five main themes and 17 subthemes were identified including (i) user's characteristics; (ii) professionals' characteristics; (iii) models of intervention; (iv) organizational health care models, and (v) health policies (Fig. 2). Example quotations for themes and subthemes are listed below.
Profile of the cannabis users at the CAS
Professionals in the groups (Gs) – especially G1 and G2- suggested that tobacco cessation interventions should consider the complexity of users who come to the CAS for consultation. However, they also pointed out that these users do not differ significantly from other users who attend other healthcare services or are in the community. They implied that cannabis users should not be socially stigmatized because of their cannabis use disorders, and as a clinical and social community, we should avoid labelling them negatively just because they have an addiction or a psychiatric problem. However, they also raised concerns about the frequent presence of social stereotypes and prejudices in Catalan (and Western) culture.
P2-G1: “I would like to make a point. Psychiatric pathology is very prevalent in the general population, as is co-morbid drug use. We see (in the clinics) those who are at the tip of the iceberg... it represents an emerging vision of what is happening”.
The professionals confirmed three common characteristics present in these users:
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The first is the high frequency of both organic and psychiatric co-morbidities among these group.
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The second is poly-drug use, as they combine several illegal drugs in addition to the associated co-dependencies.
P4-G1: “They are users who, in a high percentage, consume 3–4 substances and have serious and severe disorders.”
P7-G2: “They are users who start treatment in our outpatient clinics because they want to quit the main drug and who also smoke”.
In all three FGs, there is a consensus that users seek help at the CAS due to the problematic impact of the main drug, either voluntarily or with the assistance of their families. They are often referred by other healthcare services, mainly primary care. However, in both scenarios, they do not express a motivation to quit tobacco use, and neither they, their families, nor other health professionals in the substance use community identify tobacco as a potential treatment option.
P3-G1: "Tobacco is an invisible problem because it is underestimated compared to other substances. As the main drug is more aggressive and illegal with a greater impact, when they say they smoke and you ask how many cigarettes they smoke, they answer that they smoke only a few cigarettes, about one pack a day, because for them it doesn't matter as much as the other substances”.
Another issue to consider when adjusting interventions is that there are different patterns of cannabis and tobacco use among clients.
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On one hand, there are very young people for whom tobacco has negative connotations, unlike cannabis. Additionally, young cannabis users are not even aware that they consume tobacco when they mix it with cannabis to make joints because, for them, tobacco is not the substance they want to consume; they want to consume cannabis.
According to P1-G3: "Unlike for young people, "la maria" (slang for marijuana in Spanish) is considered good, while tobacco is seen as bad. Although they might have a negative perception of tobacco, when they consume other drugs, it is a minor issue.
As P15-G3· mentions: "Cannabis consumers are experts, but it can be considered a culture. P5 (All). Now there is a fair and everyone smokes. They are super experts. Everyone there smoking... This is "Indica"...Now I've moved to the CBD...They're young, under 30, including 40. (P15G3).
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A third group consists of moderate cannabis users aged 50–60 who have reduced their daily cannabis use and now have become occasional users, consuming one or two joints per day, or only using cannabis during the weekends.
As described by P14G3: “We attend people who now smoke only a joint per week, people who smoke a residual joint (good night on weekends). (P14G3)”
Professional characteristics
Another issue discussed in all three groups was the importance of considering the beliefs and professional practices of health professionals working in substance use programs, as these beliefs can either support or hinder the promotion of the smoking cessation support relationship.
As mentioned by a participant in P3-G1: "At this point, the belief of the professional has a lot to do with it. How they deliver the information, what they tell them... their motivation matters... it depends on their knowledge and how they handle their own relationship with tobacco."
This highlights the significance of reinforcing the role model that ensures the legitimacy of interventions.
As emphasized by P4-G1: "If the user sees the professional smoking outside, credibility is lost."
The "lead professionals" believe that they have the competencies to incorporate tobacco cessation into routine practice, just like experts in addiction who possess skills in promoting motivation among users. Furthermore, they note a generational change in the way patients are attended to in CAS.
P1-G1: “In the past, the old-school clinicians did not include tobacco cessation as part of the treatment, and those who were pioneers in doing so were considered nerds (eccentrics). Unfortunately, now many residents receive tobacco cessation training, making everything easier. In fact, some of the new clinicians have been tutored by us, and they have successfully integrated tobacco cessation into their practice. The ones from our regeneration did not have references.”
Intervention Models:
This is where some controversies were identified between the professionals of the first two FGs (lead professionals) and FG3, which consisted of professionals with less experience in smoking cessation. The more experienced professionals reported that, according to their experience, it was not crucial to decide when to offer smoking cessation during the cannabis cessation treatment. They found that it was equally effective to use either a concurrent model (quitting both substances at the same time) or a sequential approach (quitting one substance first and then the other). The key element in proposing one or the other approach relied on the users' preference, respecting their choice, while always working on motivating them to promote quitting both substances as experts in the field.
Additionally, clinicians in G1 and G2 highlighted the following actions to enhance the implementation of tobacco cessation interventions during substance use treatment.
First, it is key to align smoking cessation models with drug dependence intervention models. Thus, the cessation model should also include harm reduction, which focuses the intervention on minimizing the adverse consequences of tobacco use and not exclusively on abstinence.
P4-G1: " Of course, the idea is to increase self-efficacy, and then they take ownership of the process on their own. Harm reduction was frequently employed with heroin and alcohol before, and it proved effective (..). The same principle applies to tobacco. There are chronic patients with whom I discuss creating guidelines for quitting smoking; it's also an intriguing approach.”
In the same vein, they suggest reviewing the applicability of motivational interviewing in users with dual pathology and feel competent to approach smoking cessation with models that are more adapted to the type of user:
As expressed by P5-G1: “We have been working with addictions for many years, so we can also address tobacco. It cannot be segmented from the continuum of an intervention model. Perhaps we don't need training”.
Professionals who are part of integrated intervention systems (lead professionals), where they can work in coordination, emphasize the importance of offering follow-up programs to patients with dual pathology, which promote and reinforce abstinence from tobacco. These programs are regularly offered to both outpatient and inpatients attended in the Catalan Health System. For tobacco cessation, clinicians frequently use a sequential model, addressing the main substance first (in this case tobacco) and then focusing on tobacco.
P8-G2 explains: “At the ambulatory level, we implement a specific program for tobacco users (they are psychiatric patients with co-occurring disorders). We follow a classic approach: addressing other substances first and then tobacco. When we ask and register tobacco use in the clinical record, it’s when some individuals express their desire to quit smoking that they enter this specific program, which has a defined duration (1 year) from its beginning to end.”
These same professionals agree on implementing more holistic approaches that also promote positive changes in health, and they are already putting this into practice in interdisciplinary teams.
As stated by P9-G2: “Nurses usually work on promoting healthy lifestyles, and introduce strategies for change, such as physical activity, nutrition, motivation, ... but one aspect that all patients have in common is that they smoke. And in this way start to work on tobacco cessation.”.
However, the perception of professionals in the G3 differs. Despite agreeing with the integrated approach, they do not feel that it is being effectively put into practice. A CAS nurse expresses this concern:
P11G3: "More transversal and comprehensive interventions are needed, for example, in sports, nutrition, etc.., we should not focus only on tobacco"
In terms of therapeutic modality, the clinicians, especially the "lead professionals" highlight the benefits of group interventions, expressing in detail their practices and the impact on the users.
As stated by P7G2, CAS psychologist: “They allow you to share your experiences with other people, and you can see that there are individuals at very different stages. This has an important therapeutic effect, a ripple effect, as it resonates with you and helps you become more aware”.
On the other hand, a doctor-psychiatrist, who participated in the G3, affirms that tobacco is not addressed in the groups they lead, as they limit themselves exclusively to risk reduction.
P1-G3: “It is not addressed...only if the demand is made. They are groups focused on reducing damage and risks...”.
Organizational Models
The perception of the professionals consulted, in all three FGs, is that the current organizational/management models are still fragmented, and it is not clear how to address the physical and psychological co-morbidities of the users.
As expressed by a participant in P2G2: "It is not sense. Patients have co-morbidities, so why this partiality? why there is not a good integration between what is done in the primary care, in hospitals, and in the CAS?"
Thus, the proposal for action was:
As P13-G3 stated: “Tobacco cessation is a task that is usually done in primary care centers, but it is not included in our portfolio. We are responsible for other types of tasks, such as conducting alcohol groups and providing methadone dosage, among others. However, the general view is that no one expects us to provide smoking cessation services in CAS."
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Second, to improve organizational aspects of drug dependence care, there was a suggestion to review the smoking ban regulations, especially when hospitalization is needed. In Spain, smoking is banned in acute hospitals, indoors on all the premises, and on the grounds of acute hospitals. This introduces a challenge in treating tobacco use, especially if patients require hospitalization.
As for compliance with the smoke-free ban, there was no unanimous agreement on whether it was positive for users who are admitted to hospitals to quit their main drug. Nevertheless, some clinicians stated that the introduction of the national ban in 2011 that banned smoking forced them to introduce smoking cessation in their protocols.
As stated by P9-G2: "In our center, we have 4 beds for patients with dual pathology who enter our unit for detoxification from other drugs and are also required to quit smoking, due to the tobacco law. Substitute treatment is given to them. Upon discharge, they can enter smoking cessation programs”.
In other cases, the smoking ban was seen as a barrier to entering detoxification units:
P4-G1: "I think that those who quit the main substance when it comes to tobacco, they delay quitting, and only do it when they arrive at Primary Care. They say, 'I only have tobacco.' It doesn't help at all that Hospitalization Units do not allow smoking because then they are reluctant to enter due to the discomfort of being without tobacco."
Health policies
Participants in the FGs suggested three elements for improvement in the implementation of tobacco cessation interventions that relate to health policy regulation.
P7-G2: “It is necessary for institutional policies to change at the level of legislation on tobacco, as it has been proven that they are very effective. Currently, this lack works against us. We need 1) an increase in the price of tobacco; 2) restrictions on consumption in certain areas; and 3) advertising changes to promote awareness.".
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The second issue is the need to improve the access to better resources. In some cases, some center a large volume of patients in large territories where different types of users coexist (some are rural and other urban patients, with different profiles). What it is more they claim that there is a lack of professionals to attend to these complex individuals adequately.
P7G2: "The Addictions and Mental Health Network is the one that has had the least resources. For example, we only have 1 and a half Psychiatry professionals for 400,000 people."
P7-G2: "I think there are many professionals, overwhelmed with their workload, who cannot effectively address tobacco cessation. Some professionals even fail to inquire about tobacco use in the toxicological history. Moreover, the Drug Addiction Information System (SID), which is under the government's purview, does not include specific fields to record tobacco-related data. Instead, it focuses on standard data for conducting epidemiological studies."
From the five topics reported, two stand out the models of intervention and the engagement of clinicians in attending these two substances in their routine practice. Clinicians’ proposals to understand this complex problem should be considered to move forward this topic from their day to day of their clinical practice to a higher health policy level. Nonetheless, as the participants in FGs informed, the structural themes are interwoven among them as a change in one of them affects the other. However, the topics in which clinicians gave more importance were the models of intervention and the engagement of clinicians in attending these two substances in their routine practice. Clinicians’ proposals to understand this complex problem should be considered to move forward this topic from their day to day of their clinical practice to a higher health policy level. In addition, the structural themes) are interwoven among them as a change in one of them affects the other.