Tobacco-Related Practices and Policies in Residential Perinatal Drug Treatment Programs‪.‬

Three decades of research have documented the serious health problems resulting from maternal smoking. In addition to the well-documented effects of smoking on women's health (US DHHS 2001), added perinatal risks include low maternal weight gain, miscarriage, placenta previa and abruption, stillbirth, (CDC 2007; US DHHS 2001) and disinclination to breastfeed (Noble et al. 2003). Infants of maternal smokers are at increased risk for low birth weight, prematurity, asthma, middle-ear disease, reduced liver size, and sudden infant death (Fleming & Blair 2007; Milner, Rao & Greenough 2007; Ventura et al. 2003). In-utero and passive exposure to environmental cigarette smoke are also associated with an increased risk for childhood asthma (Vork, Broadwin & Blaisdell 2007; CDC 2006; Jaakkola & Gissler 2004), infantile colic and acid reflux (Shenassa & Brown 2004), coronary artery disease, ear infections (Gulya 1994), colds and flu, worsening of allergies, learning and behavior problems, and an increased number of pediatric hospitalizations (Moskowitz, Schwartz & Schieken 1999; Adair-Bischoff & Sauve 1998). Smoking-attributable expenditures for neonatal care were estimated to be $366 million, or $704 per smoking mother. The prevalence of maternal smoking and cost per smoker were higher for women who had late or no prenatal care compared to women who initiated care in the first trimester (Adams et al. 2002). Perinatal substance-using women smokers are especially vulnerable to other tobacco-related risks for morbidity from synergistic effects of combined substance use (Hashibe et al. 2007; Marrero et al. 2005; Salaspuro & Salaspuro 2004), inadequate prenatal care (El-Mohandes et al. 2003), and limited availability of tobacco addiction treatment in substance abuse treatment programs (Friedmann, Jiang & Richter 2007). Data on consumers in drug abuse treatment programs indicate that 80% to 95% of clients smoke (McIlvain et al. 1998), with higher smoking rates reported among in-treatment perinatal women (Bean 2007; Haug, Stitzer & Svikis 2001). Continued smoking after treatment is also a known risk factor for relapse to drug use (Lemon, Friedmann & Stein 2003), and treatment of nicotine dependence during drug abuse treatment is positively correlated with abstinence from other drugs (Hurt & Patten 2003; Sullivan & Covey 2002). Although effective tools are available to craft a clinical response through adoption of smoking cessation programs into substance abuse treatment (Institute for Health and Recovery 2002; Rustin 1998; Hoffman et al. 1997), practice change has been limited. Staff's addiction to cigarettes, minimization of tobacco effects compared to those of illicit drugs, lack of ability to implement evidence-based practices, and organizational climates of stasis have constrained clinical approaches to tobacco dependence in drug treatment settings (Montini & Guydish 2004; Hurt et al. 1995). Anxieties about insurer and community stakeholder reactions to no-smoking rules have also been anecdotally cited as barriers to inclusion of tobacco treatment in women's programming (Harrison 2006; Stanley 2006).