|Year : 2020 | Volume
| Issue : 2 | Page : 84-90
Nicotine Dependence, Readiness to Change Behavior among Tobacco Users Attending Tertiary Care Hospital's De-Addiction Clinic in Uttarakhand
Rajesh Kumar1, Hoineiting Rebecca Haokip1, Kalpana Beniwal2, Yogesh Bahurupi3
1 College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||26-Dec-2020|
|Date of Decision||21-Sep-2020|
|Date of Acceptance||28-Dec-2020|
|Date of Web Publication||08-Feb-2021|
Dr. Rajesh Kumar
College of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Introduction: Tobacco use is a significant cause of many respiratory diseases and preventable deaths in India. The crunch of information on the magnitude of the tobacco use problem unable to planned and implement tobacco cessation programs in the Himalayan region. This study aims to determine nicotine dependence and readiness to change behavior in tobacco users attending a tertiary care teaching hospital's de-addiction clinic. Materials and Methods: This descriptive study purposively included 120 tobacco users over 6 months in a public hospital's de-addiction clinic, North India. A structured personal and clinical profile sheet, the Fagerstrom Test for Nicotine Dependence-Revised Version-smokable and smokeless), and Readiness to Change Questionnaire (RCQ) were used to collect information. Descriptive and inferential statistics were used to generate the findings. Results: The mean age of tobacco initiation was 20.69 (±6.12) years in the study population, with a median ofthree quit attempts (median: 3; interquartile range: 2–5). Nearly 55.8% and 18.3% of participants were using smokable and smokeless tobacco, respectively. Bidi was the most preferred (75.8%) form of smokable tobacco among study participants. The majority of participants were in the category of high nicotine dependence (76.6%) as per the FTND scale and were in the contemplation phase (55%), whereas 45% of the users found it in the action stage of quitting tobacco. Conclusions: The majority of the participants were in the high nicotine dependence stage. However, readiness to change behavior to quit or reduce tobacco use is noteworthy, emphasizing need-based intervention and assisted follow-up programs to tobacco users in the outpatients.
Keywords: Nicotine dependence, readiness, tobacco
|How to cite this article:|
Kumar R, Haokip HR, Beniwal K, Bahurupi Y. Nicotine Dependence, Readiness to Change Behavior among Tobacco Users Attending Tertiary Care Hospital's De-Addiction Clinic in Uttarakhand. Indian J Psy Nsg 2020;17:84-90
|How to cite this URL:|
Kumar R, Haokip HR, Beniwal K, Bahurupi Y. Nicotine Dependence, Readiness to Change Behavior among Tobacco Users Attending Tertiary Care Hospital's De-Addiction Clinic in Uttarakhand. Indian J Psy Nsg [serial online] 2020 [cited 2021 Sep 21];17:84-90. Available from: https://www.ijpn.in/text.asp?2020/17/2/84/308835
| Introduction|| |
Tobacco use is a significant public health problem in India cause many health problems. In India, around 300 million people live below the poverty line, and out of them, 28.6% of the people consume tobacco in one or another form. Tobacco attributable mortality is significantly high in India. Tobacco use leading adverse impacts on the human body and risk factors for various diseases ranging from periodontal problems, cerebrovascular diseases, dementia, stroke, and cancer of different kinds.
India's survey reported an 18.4% and 21% prevalence of tobacco smoking and chewing, respectively. Compared to women, Indian men were much more more likely to chew tobacco (29% vs. 13%), smoke tobacco (33.3% vs. 3,4%), and consume tobacco in both forms (50.2% vs. 15.5%). Similarly, it has been reported that more number of the population uses smokeless tobacco products (21%), followed by smoke tobacco (9%) and both (5%).,
Tobacco use and pattern vary globally. India has a big market for tobacco and the second-largest number of consumers of tobacco. India alone has more tobacco consumers than the population of Western Europe. The use of raw tobacco products in the Himalayan belt is significantly higher, considering the region's abundant availability and production., Controlling wild and illegal cultivation of tobacco in the Himalayan belt is nearly impossible.
The use of many pharmacological and behavioral approaches was found useful in quitting tobacco use., However, using a relevant and population-tailored intervention could be an alternative strategy to meet the needs and interests of the population of different cultural conditions.
In today's world, tobacco's health hazards are well known, and many tobacco users want to quit tobacco use. In an earlier published report, 68% of current tobacco users want to agree to quit tobacco, and 60% quit for a day relapse in a week. However, only 7% maintained abstinence for the next 6 months, and 45% ended in relapse. Many tobacco users try to quit tobacco every day, but only a few succeed in maintaining abstinence for more than just a week or month. Tobacco abstinence needs continuous motivation, drug-adherence, professional guidance, and assistance through instant messaging and telephone. Further, earlier work also used mobile services for constant encouragement, advice, and tips to quit tobacco; motivational reminders and tracking progress were also beneficial.
Background information on magnitude, consumption patterns, trends, and implementation of tobacco control policies is essential to developing a target-based intervention. Therefore, the present study attempted to understand the pattern of tobacco use, nicotine dependence, and readiness to change behavior among tobacco users attending a de-addiction clinic in North India.
| Materials and Methods|| |
We conducted this cross-sectional survey in a psychiatric department's de-addiction clinic at a newly developed tertiary care public hospital, North India. De-addiction clinic is a specialized unit under the department of psychiatry providing services to different kinds of patients with substance use. The clinic receives patients with various substance use such as tobacco, alcohol, marijuana, drugs, polysubstance use, cannabis, opioids, and many more. This study purposively recruited 120 patients currently using tobacco in any form in the study. Patients who had undergone treatment for minor and major psychiatric disorders as per ICD-10 were included in the study. However, patients with severe psychiatric disorders and uncooperative were excluded from the present work. A self-developed structured and pre-tested personal and clinical profile sheet and The Fagerström Test for Nicotine Dependence (FTND-Smoking version), Modified Fagerström Test for Nicotine Dependence (FTND-smokeless), and Readiness to Change Questionnaire (RCQ) is used to collect information on variables of interest. Details of the instruments are provided in the below section;
Sociodemographic and clinical profile sheet
The researchers used a personal and clinical characteristics sheet to collect information on participants' age, gender, current residential area, education, marital status, family structure, religion, and monthly family income (BG Prasad Scale). Tobacco profile included information on types of tobacco products, age of tobacco initiation, frequency of using tobacco products, types of tobacco use, and smoking, the reason of initiation and relapse, self-perceived readiness to quit tobacco, number and duration of quit attempts, and complications of tobacco use, and history of any illness.
Nicotine dependence status
Study participants were screened using The Fagerström Test for Nicotine Dependence (FTND-Smoking version) and Modified Fagerström Test for Nicotine Dependence (FTND-smokeless for the severity of nicotine dependence. Similar earlier work widely used scales to assess the severity of nicotine dependence in tobacco users. Both the scales use a 1–10-point scale to rate the nicotine dependence, where a score >3 or 4 indicates low-moderate nicotine dependence. Scales have good discriminative and convergent validity, had good test–retest reliability, and were used extensively in preceding studies.,,, The higher score on the scales guides intense physical dependence on nicotine and suggests treating withdrawal symptoms, preferably with nicotine replacement therapy (NRT).
Readiness to Change Questionnaire
This questionnaire was used to measure motivation to quit tobacco use among the participants. The questionnaire consists of 12 items and originated using Prochaska and DiClemente's stage of change model, which suggest three stages of change, namely, (1) precontemplation stage (not thinking about stopping tobacco); (2) contemplation stage (ambivalent about stopping tobacco use), and (3) action and maintenance stage (reduced or stop using tobacco). The participants were asked to rate their response on a 5-point rating scale; strongly disagree (−2), disagree (−1), unsure (0), agree (+1), and strongly agree (+2). Each subscale score needs to sum up at the end to calculate the total score of a participant. The questionnaire has satisfactory internal consistency and reliability and is used widely for a similar population in the past. The institutional ethics committee approved the study. Written informed consent was collected from the individual participant, and privacy and confidentiality were ensured at each research phase. A sample size of 358 was calculated for the study. However, considering the COVID-19 outbreak between the data collection period (October 2019–March 2020), the study's analyzed sample size could not be achieved. All statistical analysis was carried out using SPSS software version 23 (IBM Corp, Armonk, NY, USA). We used frequency, percentage, and other appropriate descriptive statistics to describe the study participants' personal and clinical characteristics. Nicotine dependence and readiness to change behavior status computed using relevant statistics. Further, an appropriate descriptive statistic was applied to compute the results on FTNDS, FTNDS-ST, and readiness to change behavior. Chi-square test is applied to find the association of sociodemographic charecteristics with the radeiness to change behaviour of the participants.
| Results|| |
The total number of subjects was 120 in the study. The majority of patients were males (93.3%) with a mean age of 49.09 (±12.57) years. Most of the patients were married (90.3%). More than three-fourth (78.3%) of patients were completed intermediate education and were Hindu (78.3%) by religion.
More than half (59.1%) of the patients worked in a private job and belonged to rural areas (80%). Of the participants, 35.8% of patients were in the lower-middle class income category (as per BG Prasad socioeconomic scale) and belonged to a joint family system (70%). Chi-square test shows no significant association of sociodemographic variables with readiness to change behavior [Table 1].
Tobacco use profile
Regarding tobacco use, the mean age of tobacco initiation was 20.69 (±6.12) years and taken 3 (interquartile range: 2–5) quit attempts. The mean body mass index was 22.17 (±3.35) of the patients. More than half (55.8%) of patients using smokable tobacco, followed by 18.3% using smokeless, and the remaining 25.8% were using a combination of both forms of tobacco. Bidi (75.8%) and safal/gutkha (26.7%) were common in using smokable and smokeless tobacco products, respectively. In terms of asking for the frequency of use, 32.5% of patients were using <10 bidi/cigarettes, followed by 29.2% of participants using 11–20 bidi/cigarettes per day. Similarly, an equal number of patients (19.2%) using 2–3 can/pouch and more than three cans of smokeless tobacco products every day.
The majority of patients (80.8%) reported peer pressure as a common reason for tobacco initiation and relief from physical problems (65%) a reason for relapse. Nearly 94.2% of patients reported physical complications after initiating tobacco use and mentioned a history of psychiatric illness (88.3%). On asking readiness to quit tobacco use, 78.3% of patients were ready to quit, followed by 17.6% were in the ambivalent phase, and still 5% were not ready to quit tobacco use and reported unhealthy (65%); however, they look interested in reducing tobacco use. Information on the pattern of tobacco use is summarized in [Table 2].
Nicotine dependence status
The Fagerström Test for Nicotine Dependence (FTNDS-Smoking version) and Modified Fagerström Test for Nicotine Dependence (FTNDS-smokeless) were used to assess the severity of nicotine dependence status in patients. All 120 patients screened using FTNDS and reported that 33.3% and 43.3% of patients were in the high dependence category in smokable and smokeless tobacco products use, respectively. However, 9.17% and 10.83% of patients fall in the very low to low dependence category in smokable and smokeless tobacco products use, respectively [Table 3].
Readiness to change behavior
The motivation to quit tobacco use was measured using the readiness to change questionnaire (RCQ). This instrument was developed based on the stage of change theory and used to assess an individual's motivation and categorize the stage of individual changes. Based on this questionnaire, it helps to classified the participants into three stages (1) precontemplation, (2) contemplation, and (3) action stage. More than half (55%) of subjects were in the contemplation stage of change. Approximate half (45%) of the participants were in the action stage, determined to quit and take a move forward for a new beginning of life [Figure 1].
| Discussion|| |
We conducted the study at a de-addiction clinic attached to the psychiatry department at one of the apex tertiary care health center, North India. One hundred and twenty patients with tobacco use provided information on their tobacco profile, nicotine dependence, and readiness to change behavior. The majority of patients were males (93.3%) with a mean age of 49.09 (12.57) years. Nearly 30% were self-employed and were never attended school (22.5%) for formal schooling and were married (88.3%). These findings are in the consensus of a hospital-based study on the sociodemographic and clinical profile of the substance abuse population in where a majority of the subjects (98%) were males, married (40%), and gainfully involve in some self-business (31%). However, the mean age of the subjects in this work is advanced compared to the earlier study.
All the 120 participants meet nicotine dependence criteria (FTNDS >3 or 4) in this study. Smoking was the most popular form of tobacco, being used by 55.98% of the subjects, over 18.3% smokeless, and 25.8% both smokable and smokeless tobacco products. The use of bidi was common (75.8%), followed by cigarettes (5.8%). Of the smokeless tobacco users, 26.7% used gutkha, hatigola (local tobacco product in Western Uttar Pradesh) (7.5%), and pan masala and other smokeless tobacco products (9.2%). Smoking is reported as one of China's common tobacco forms and Western literature. In India, the regional difference in production and availability of tobacco products reflects variation in prevalence across the country.,
In the study, the mean age of initiation is 21 years for tobacco products. Much of Indian literature emphasized tobacco use in adolescent age and reported tobacco use in individuals aged 15 years or above., A study on school and college adolescents also reflects tobacco use in the age group of 10–15 years of age.
The present study reported no significant association of sociodemographic variables with the readiness to change behavior. However, contradictory findings reported in earlier published work on a significant association of the motivation to a younger age, residential location, self-reported health, education status, and socioeconomic level of the subjects. The variation in findings may be presumed to result from smaller sample sizes and settings and warrant further investigations in North India.
Fagerstrom Test for Nicotine Dependence questionnaire was used to quantify the nicotine dependence status among tobacco users. Findings reflect that 33.3% and 43.3% of patients were in a higher nicotine dependence stage in the smoking and smokeless groups, respectively. These findings are alarming and indicate that patients reporting to the de-addiction center are on excess use of tobacco products and have a high nicotine dependence level. These findings are in line with the many existing Indian literature on nicotine dependence.,, This high level of tobacco use and nicotine dependence indicates a high risk for detrimental effects on physical and psychological health and undue expenditure on individual, family, and economic burden on the country. The clinical perspective suggests developing culturally appropriate and behaviourally specific therapies or interventions to facilitate abstinence and motivate them to quit smoking, reduce unpleasant symptoms, and control relapse.,,
The use of individually tailored intervention helps meet the patient's unique needs during the abstinence, discomfort, and meet the individual's expectations to control the relapse. Thus, the use of individually tailored and linguistically appropriate intervention would have control over tobacco-related withdrawal and addiction symptoms.
The motivation ruler's findings indicate that more than 55% of the patients were in the contemplation stage, and 45% were in the action stage. These findings indicate that a large proportion of the patient's thinking about quitting tobacco use and started taking necessary action in that direction. Much of the existing literature on readiness to change behavior indicates that smoking patients are interested in quitting tobacco use.,, However, the clinician's role is crucial at the contemplation stage of readiness to change. The clinician would help a patient on his ambivalence state of mind by reflecting realistic psychoeducation on tobacco-related health hazards and explaining the quitting benefits at the current stage. The use of motivational interviews, cue technique, cognitive behavior therapy, patient and family counseling, and self-support groups also has good quitting tobacco.
Every clinician is eager to see his patient in the action stage. Nicotine dependence is a chronic condition and need long term and repeated treatment and efforts. The motivation for change is an important component of nicotine treatment and should be assessed at each time. Managing withdrawal symptoms and dealing with smoking cues or precipitants is a challenge for an individual. During the action stage, the focus is to strengthen efforts and self-efficacy, help patients manage withdrawal symptoms, temptations, and craving to use tobacco products by giving medical help such as NRT or suggesting positive coping strategies.,,
The findings will be insightful for a psychiatric nurse either working in a community or hospital setting. These findings will help her understand the magnitude and pattern of tobacco use predominant in the area and preventive design strategies to reduce hazardous use.
| Conclusions|| |
The majority of the patients using tobacco in or another form and diagnosed with nicotine dependence in the study. A large number of patients started thinking about quitting and taking action to quit tobacco use.
Tobacco dependence is a chronic condition warrant long-term and repeated treatment, along with motivation and counseling services. Besides psychopharmacological treatment, behavioral, and tailoring treatment protocols for individuals will help improve abstinence and tobacco-free days.
This preliminary survey had a few limitations. The cross-sectional nature of the survey limits establishing a causal association of tobacco use's personal and clinical characteristics and readiness to change behavior. Further, the COVID-19 outbreak in data collection limited the sample size and hence, limits its generalizability. Furthermore, the self-reported nature of findings might affect data reliability. The study only collected information from participants visiting the de-addiction from the remote hilly region; therefore, they cautioned other researchers to extrapolate the findings in another setting.
Despite limitations, the preliminary findings suggest clinicians insight into the types of tobacco use among the population residing in the remote Himalayan region and develop a more acceptable intervention to curb the problem.
Tobacco use is a common and widely prevalent condition among all types of substance abuse and remains a significant cause of premature deaths globally. A comprehensive management approach needs a detailed assessment of types of tobacco use, nicotine dependence, and stage of change to recommend an appropriate treatment plan. Development of institution-level policy on identification, documentation, and treatment approach for different types of tobacco users may bring remarkable changes in nicotine dependence treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
UNDP. Poverty Reduction and Livelihoods Promotion. Available from: http://www.in.undp.org
. [Last accessed on 2020 Jul 30].
Ahmed FM, Peeran SV. Review article: Significance and determinants of tobacco use: A brief review. Dent Med Res 2016;4:33-8. [Full text]
Subramanian SV, Nandy S, Kelly M, Gordon D, Davey Smith G. Patterns and distribution of tobacco consumption in India: Cross sectional multilevel evidence from the 1998-9 national family health survey. BMJ 2004;328:801-6.
World Health Organisation (WHO). Tobacco or Health: A Global Status Report. Geneva: WHO; 1997.
Saha I, Islam K, Paul B, Som T. Nicotine dependence and its correlates among the adult tobacco users in a slum of Burdwan district, West Bengal, India. J Fam Med Prim Care 2017;6:813-8.
Global Adult Tobacco Survey (GATS) India. International Institute of Population Sciences, Mumbai. New Delhi: Ministry of Health & Family Welfare, Government of India; 2010.
Mishra GA, Pimple SA, Shastri SS. An overview of the tobacco problem in India. Indian J Med Paediatr Oncol 2012;33:139-45.
] [Full text]
Kumar R, Kataria N, Radhakrishnan DM, Niraj K. Clinico-epidemiological profile of stroke patients in the Himalayan Subcontinent – A retrospective study. Natl J Physiol Pharm Pharmacol 2020;11:17-22. Available from: http://www.njppp.com/fulltext/28-1597029875.pdf?1607141691
. [Last accessed on 2020 Jul 24].
Kuddus M, Ginawi IA, Al-Hazimi A. Cannabis sativa: An ancient wild edible plant of India. Emirates J Food Agric 2013;25:736-45.
Juyal R, Bansal R, Kishore S, Negi KS. Socio-demographic characteristics of substance abusers among intercollege students in a district of Uttarakhand. JK Science 2008;10:116-9.
Hatsukami D, Jensen J, Allen S, Grillo M, Bliss R. Effects of behavioral and pharmacological treatment on smokeless tobacco users. J Consult Clin Psychol 1996;64:153-61.
Haddad L, Corcoran J. Culturally tailored smoking cessation for arab american male smokers in community settings: A pilot study. Tob Use Insights 2013;6:17-23.
Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults — United States, 2000–2010. Morb Mortal Wkly Rep 2017;65:1457-64.
Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2016;4:1-52.
Bricker JB, Mull KE, McClure JB, Watson NL, Heffner JL. Improving quit rates of web-delivered interventions for smoking cessation: Full-scale randomized trial of WebQuit.org versus Smokefree.gov. Addiction 2018;113:914-23.
Debnath DJ, Kakkar R. Modified BG Prasad Socio-economic Classification, Updated – 2020. Indian Journal of community health 2020;32:124-5.
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.
Hatsukami DK, Stead LF, Gupta PC, Sekhsaria H. Tobacco addiction: Diagnosis and treatment dorothy. Lancet 2008;371:2027-38.
Ebbert JO, Severson HH, Croghan IT, Danaher BG, Schroeder DR. A randomized clinical trial of nicotine lozenge for smokeless tobacco use. Nicotine Tob Res 2009;11:1415-23.
Haokip HR, Kumar R, Rawat VS, Sharma SK. Efficacy of standard nicotine replacement therapy (NRT) versus video-assisted nurse-led NRT on tobacco cessation: A randomized controlled pilot trial; 2021;9:141-6. Available from: https://doi.org/10.1016/j.cegh0.2020.08.004
. [Last accessed on 2020 Jul 24].
Jhanjee S, Balhara YP, Sethi H. Tobacco use among drug dependent patients in treatment setting. Delhi Psychiatry J 2009;12:247-51.
Buckley TC, Mozley SL, Holohan DR, Walsh K, Beckham JC, Kassel JD. A psychometric evaluation of the Fagerström Test for Nicotine Dependence in PTSD smokers. Addict Behav 2005;30:1029-33.
Rollnick S, Heather N, Gold R, Hall W. Development of a short 'readiness to change' questionnaire for use in brief, opportunistic interventions among excessive drinkers. Br J Addict 1992;87:743-54.
Prochaska JO, DiClemente CC. The transtheoretical approach. In: Handbook of Psychotherapy Integration. 2nd
ed. New York, NY, US: Oxford University Press; 2005. p. 147-71.
IBM Corp. IBM SPSS Statistics for Windows: Version 23.0. 2011:IBM Corp, Armonk, NY, USA.
Din NU, Khan AW, Suhaff AA, Hussain Z, Ganai AM, Ahmad MS, et al
. Socio-demographic & clinical profile of patients with substance use disorders seeking treatment. A hospital-based study. Res Med Eng Sci 2019;7:808-14.
He H, Pan L, Cui Z, Sun J, Yu C, Cao Y, et al.
Smoking prevalence, patterns, and cessation among adults in Hebei Province, Central China: Implications from China National Health Survey (CNHS). Front Public Health 2020;8:177.
Singh A, Ladusingh L. Prevalence and determinants of tobacco use in India: Evidence from recent Global Adult Tobacco Survey data. PLoS One 2014;9:e114073.
Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4.
Kapoor SK, Anand K, Kumar G. Prevalence of tobacco use among school and college going adolescents of Haryana. Indian J Pediatr 1995;62:461-6.
Panda R, Venkatesan S, Persai D, Trivedi M, Mathur MR. Factors determining intention to quit tobacco: Exploring patient responses visiting public health facilities in India. Tob Induc Dis 2014;12:1.
Akram S, Gururaj NA, Nirgude AS, Shetty S. A study on tobacco use and nicotine dependence among plywood industry workers in Mangalore city. J Evol Med Dent Sci 2015;4:5729-35.
Parashar M, Agarwalla R, Mallik P, Dwivedi S, Patvagekar B, Pathak R. Prevalence and correlates of nicotine dependence among construction site workers: A cross-sectional study in Delhi. Lung India 2016;33:496-501.
] [Full text]
Woodruff SI, Talavera GA, Elder JP. Evaluation of a culturally appropriate smoking cessation intervention for Latinos. Tob Control 2002;11:361-7.
Silveira Balbani AP, Montovani JC. Methods for smoking cessation and treatment of nicotine dependence. Rev Bras Otorrinolaringol 2005;71:820-6.
Tidey JW, Rohsenow DJ, Kaplan GB, Swift RM, Adolfo AB. Effects of smoking abstinence, smoking cues and nicotine replacement in smokers with schizophrenia and controls. Nicotine Tob Res 2008;10:1047-56.
Clemmey P, Brooner R, Chutuape MA, Kidorf M, Stitzer M. Smoking habits and attitudes in a methadone maintenance treatment population. Drug Alcohol Depend 1997;44:123-32.
Richter KP, Gibson CA, Ahluwalia JS, Schmelzle KH. Tobacco use and quit attempts among methadone maintenance clients. Am J Public Health 2001;91:296-9.
Frosch DL, Shoptaw S, Jarvik ME, Rawson RA, Ling W. Interest in smoking cessation among methadone maintained outpatients. J Addict Dis 1998;17:9-19.
Elshatarat RA, Yacoub MI, Khraim FM, Saleh ZT, Afaneh TR. Self-efficacy in treating tobacco use: A review article. Proceedings of Singapore Healthcare 2016;25:243-8.
Kadden RM, Litt MD. The role of self-efficacy in the treatment of substance use disorders. Addict Behav 2011;36:1120-6.
[Table 1], [Table 2], [Table 3]