Dear Editor,
Despite significant progress in tobacco control measures and stringent smoking policies, cigarette smoking remains one of the largest preventable causes of death and disability worldwide. The World Health Organization estimates that over 8 million global deaths are attributed to smoking yearly, and in Singapore, more than 2,000 Singaporeans die prematurely due to smoking-related diseases each year.1,2
Smoking prevalence rates are exceptionally high among at-risk populations with comorbid substance addictions (i.e. alcohol or drugs), approximately 2 to 4 times higher than the general population.3 Relatedly, users of alcohol and illicit drugs also smoked more heavily and had lower success rates in quitting smoking compared to non-users.4
Less is known however about the perceived barriers to stopping smoking among individuals seeking substance addiction treatment in Singapore. Addressing these challenges is crucial in treating substance use disorders as quitting smoking improves long-term abstinence and enhances substance addiction recovery.5
This cross-sectional study spanned from March 2020 to October 2021 using convenience sampling to recruit 100 outpatients seeking treatment for substance use addictions at the National Addictions Management Service (NAMS), a tertiary addiction treatment centre located within Singapore’s only psychiatry hospital, Institute of Mental Health.
Information on demographics, smoking history and substance use profile was collected. This included onset age of substance use (including smoking), duration of use, quit smoking attempts, longest quit duration, current intention to quit, and reasons for not seeking NAMS smoking cessation services. The Challenges to Stopping Smoking scale (CSS-21) was administered to assess intrinsic and extrinsic challenges impacting participants’ quit attempts.6
A consistent theme emerged: participants perceived that they lacked the desire or willpower for smoking cessation, while others felt they had the ability to exercise self-control and quit on their own. For some participants, focusing on their primary addiction to alcohol or drugs took precedence over quitting smoking. Smoking was also used as a stress relief aid, while majority struggled with multiple quit attempts and had short periods of abstinence.
Additional themes included indifference towards smoking as a concern and the influence of families and friends who smoked. Notably, participants’ reluctance to seek smoking cessation treatment was influenced by factors such as cost and accessibility. Additionally, the unavailability of cessation services during non-work hours was a significant deterrent.
On analysing the CSS-21 responses, major challenges on the intrinsic subscale were easy cigarette availability; withdrawal symptoms when trying to stop smoking; being addicted to smoking; and reminders of smoking. Extrinsic challenges included difficulty finding support; cost of stop-smoking medicines; fear of failure; and belief in one’s ability to stop smoking in the future if necessary (Table 1).
Table 1. Intrinsic and extrinsic factors of Challenges to Stopping Smoking scale (n=100).
This study highlighted the challenges to smoking cessation among patients seeking help for substance use disorder. Participants faced difficulties in quitting smoking, which could undermine substance abuse recovery. Substance users also faced difficulties maintaining abstinence during smoking cessation, especially when using smoking as a stress reliever or substitute for alcohol and drugs.
Participants considered smoking a secondary issue, focusing on their primary addiction problems. Earlier studies reported that illicit drug use negatively affected smoking cessation success, possibly due to continued drug use hindering their ability to quit smoking. As such, smokers with substance addiction issues may have stronger motivations to continue smoking.7
Nearly half of our sample population experienced difficulty quitting smoking due to withdrawal symptoms accompanying smoking cessation. Similarly, studies have found recurring themes among patients with substance use disorders expressing fears and anxieties about withdrawal symptoms when quitting cigarettes, in addition to the continued use of smoking as a coping mechanism. Notably, McHugh et al. found that among substance-using inpatients, over 80% perceived anxiety towards smoking cessation with at least 60% lacking the confidence in quitting and maintaining sobriety.8
Focusing on quitting barriers among individuals with alcohol problems, Asher et al. found that irritability and restlessness emerged as prominent withdrawal-related barriers that hindered smoking cessation. Concerns about intolerable urges to resume smoking post-smoking cessation and its effects on maintaining alcohol sobriety were also prevalent in their sample.9
Results from our study highlighted extrinsic barriers to treatment; particularly, costs and accessibility to treatment featured prominently as impediments to smoking cessation. Smoking cessation costs in Singapore are high, estimated at SGD200 to SGD300 (approx. USD150–220 in 2024) per month for nicotine replacement therapy or medications excluding consultation charges. Advocating for policies aimed at reducing cost of smoking cessation treatments could benefit our treatment-seeking population.
Additionally, the study emphasised the importance of structured smoking cessation programmes across the island, offering both counselling and pharmacological options to improve treatment accessibility. Better access to community-based pharmacies and clinics can further bolster the accessibility and affordability of cessation services. Improving after-hours access by extending operating hours for smoking cessation services can accommodate diverse schedules and increased engagement in smoking cessation interventions.
Providing smoking cessation interventions alongside addiction treatment positively affects substance use outcomes. Educating substance users who smoke about the importance of quitting smoking as a critical component of their recovery journey is important in motivating them to actively participate in smoking cessation programmes. Offering smoking cessation as an integrated treatment approach that concurrently addresses cravings for both substance use and smoking equips patients with the skills to effectively manage dual triggers simultaneously. Treating in tandem can prevent patients from substituting smoking for substance use or vice versa.
Clinicians treating substance-using smokers should consider providing corrective feedback regarding withdrawal symptoms and structure intervention plans to mitigate concerns about smoking cessation. Clinicians should also address concerns about the effects of smoking cessation on alcohol and drug abstinence. Interventions and treatment services should address realistic fears, such as withdrawals and fear of weight gain to enhance smoking cessation services and increase patients’ confidence in quitting smoking.
Lastly, group therapy leveraging peer support and shared experiences provides insights to counter easy access to cigarettes and social support limitations in resisting smoking. These recommendations are geared towards improving smoking cessation interventions during substance addiction treatment to foster engagement in cessation efforts, enhance success rates, and to curb smoking-related chronic diseases and mortality within this vulnerable group.
Disclosure
The authors declare no conflict of interest.
Ethics approval
Ethical approval was obtained from the Domain Specific Review Board of the National Health Group and Institutional Review Board (DSRB No. 2019/01024).
Funding source
This research was supported by National Addictions Management Service, Institute of Mental Health, Singapore.
Acknowledgements
Dr Edimansyah Abdin gave expertise advice in the statistical analyses and interpretation of the data. The authors would also like to acknowledge all research staff involved in this study (Chia Xin Yi Doris, Syidda Amron, Noor Azizah Zainuldin, Tan Hui Shan).
Keywords: addictions, addiction treatment, smoking cessation, substance abuse
Correspondence
Zaakira Mahreen Shahul Hameed, Research Officer, National Addictions Management Service, Institute of Mental Health, 10 Buangkok View, Singapore 539747. Email: [email protected]
References
- World Health Organization. Fact Sheet: Tobacco. Updated 31 July 2023. https://www.who.int/news-room/fact-sheets/detail/tobacco. Accessed 25 July 2022.
- Ministry of Health, Singapore. Singapore to introduce standardised packaging and enlarged graphic health warnings, 31 October 2018. Available at https://www.moh.gov.sg/news-highlights/details/singapore-to-introduce-standardised-packaging-and-enlarged-graphic-health-warnings. Accessed 25 July 2022.
- Callagahan RC, Gatley JM, Sykes J, et al. The prominence of smoking-related mortality among individuals with alcohol- or drug-use disorders. Drug Alcohol Rev 2018;37:97-105.
- Weinberger AH, Funk AP, Goodwin RD. A review of epidemiologic research on smoking behavior among persons with alcohol and illicit substance use disorders. Prev Med 2016;92:148-59.
- McKelvey K, Thrul J, Ramo D. Impact of quitting smoking and smoking cessation treatment on substance use outcomes: an updated and narrative review. Addict Behav 2017;65:161-70.
- Thomas D, Mackinnon AJ, Bonevski B, et al. Development and validation of a 21-item challenges to stopping smoking (CSS-21) scale. BMJ Open 2016;6:e011265.
- Stapleton JA, Keaney F, Sutherland G. Illicit drug use as a predictor of smoking cessation treatment outcome. Nicotine Tob Res 2009;11:685-9.
- McHugh KR, Votaw VR, Fulciniti F, et al. Perceived barriers to smoking cessation among adults with substance use disorders. J Subst Abuse Treat 2017;74:48-53.
- Asher MK, Martin RA, Rohsenow DJ, et al. Perceived barriers to quitting smoking among alcohol dependent patients in treatment. J Subst Abuse Treat 2003;24:169-74.
