Providing staff training enhances skills and knowledge—and also changes attitudes. With appropriate skills and knowledge, staff members often recognize that part of their role is to treat tobacco dependence—and that this is not just primary care’s responsibility. They can better appreciate that tobacco use must be addressed because of the increased morbidity and mortality among their patients. In addition, environmental tobacco smoke (ETS) affects both smokers and nonsmokers. Children, people with existing cardiac disease, and older adults are particularly vulnerable to the health consequences of ETS. Many staff members are surprised to learn that tobacco use is the number one preventable cause of death in the United States (CDC 2001) (see Figure). More addiction treatment programs and clinicians are recognizing that addressing tobacco dependence is important for promoting wellness and recovery. All smokers should be encouraged to seek tobacco dependence treatment at some point in their recovery, and addiction treatment staff can readily learn to use the evidence-based psychosocial treatments and integrate their use with appropriate medications (including several over-the-counter options). System-level reminders to trigger staff to screen, assess, and treat tobacco dependence routinely are needed to ensure that tobacco dependence treatment skills are utilized (Ziedonis et al. 2006). Strategies for treating patients at all levels of motivation to quit are important. Effective brief interventions for addressing tobacco dependence in less motivated smokers have been evaluated (Steinberg et al. 2004) and may be useful for addressing tobacco in addiction treatment populations.
Training staff members to treat tobacco dependence also helps change the treatment culture by correcting many of the misconceptions or “clinical lore” about tobacco—such as “tobacco is not a real drug,” “it’s too hard to address all the substances together,” and “quitting tobacco will definitely worsen other substance recovery.” Clearly, tobacco is both addictive and deadly—even if the serious health consequences are not immediate and do not disrupt the patient’s life as dramatically as other substances with regard to legal, employment, and family problems. Patients are apt to minimize the impact of all their drug use, especially when the consequences are not immediate and visible. Staff members know how to address this type of rationalization and denial regarding other substances. For programs that continue to allow smoking at breaks, there are opportunities to observe patients’ regressive behaviors during breaks—when many behaviors can shift back to a “bar scene.” Staff members can effectively discuss these changes during treatment, as they may mirror prerelapse risk behaviors after discharge.
Some staff members believe that quitting tobacco would be too stressful during treatment. Of course, some patients who smoke will not object, and some patients may also believe that they do not have to stop marijuana when they quit alcohol or stop alcohol use when their primary drug is heroin. Patients may express their own concerns that the urge to smoke will be intolerable, withdrawal will be very difficult, quitting will affect their primary recovery, and they may actually need cigarettes to help them cope with stress (Asher et al. 2003). In fact, evidence suggests that the opposite can occur—that tobacco use can harm, rather than enhance, recovery from other substance use by its ability to trigger other substance use (Williams et al. 2005; APA 2006).
Another potential barrier is that some staff may believe that their patients are just not interested in quitting smoking. As a result, the staff will not discuss the issue of tobacco dependence and quitting. However, many substance abusers are interested in quitting smoking as part of recovery (Ziedonis and Williams 2003; APA 2006). Although more than half of patients who smoke believe that quitting smoking will be the hardest addiction for them to address (Kozlowski et al. 1989), there is evidence that tobacco addiction can be treated successfully in addiction treatment programs, both immediately and later in the recovery process. In a recent meta-analytic review of randomized trials of smoking cessation in substance abuse settings, Prochaska and colleagues (2004) concluded that patients engaging in tobacco dependence treatment had better overall substance abuse treatment outcomes at 6 months after treatment compared with those who did not engage in tobacco dependence treatment. The exact best timing for an individual patient is less clear (Joseph et al. 2004); however, the key is to assess and make a plan to treat tobacco dependence at some point during treatment and/or recovery.
Smoke-Free Buildings and Resistance to Smoke-Free Grounds
Secondhand tobacco smoke poses a real health risk to everyone exposed to the smoke, and the issue is well addressed in the recent Surgeon General’s Report on Secondhand Smoke (U.S. Department of Health and Human Services 2006). The Textbox below lists the key findings from this report. The need to provide clean indoor air has resulted in policy changes to require smoke-free buildings in many workplaces and public settings, including health care facilities. Although there was initial resistance to smoke-free buildings by some addiction treatment staff, State laws and requirements set by the Joint Commission on Accreditation of Healthcare Organizations have changed the norm to smoke-free buildings for treatment. In addition to smoke-free buildings, some inpatient workplaces (including addiction treatment programs) have taken an additional step toward addressing tobacco by implementing “smoke-free grounds.” This step means that tobacco smoking is not allowed anywhere on the grounds of the addiction treatment program, rather than just being prohibited in the buildings. Having entirely tobacco-free grounds is an additional policy change that some States have now mandated for their treatment programs (see Sidebar on pp. 236–240).
Staff members who smoke often initially oppose the “smoke-free grounds” level of program change. Program leaders, administrators, or staff members also may have concerns that patients will act out, have worse withdrawal, leave against medical advice (AMA), or seek treatment at competing programs that allow smoking. Contrary to expectations, treatment programs with smoke-free grounds often report less acting out, less haggling about smoke breaks/number of cigarettes allowed, less coercion of smokers by either peers or staff, no increase in the AMA discharge rate, increased likelihood of completed treatment, and an increase in the number of patients seeking treatment (APA 2006; Williams et al. 2005; Hurt et al. 1995).
Other cultural milieu barriers are subtle. Some programs still sell cigarettes with the profits contributing to one of the few “discretionary” funds to which these programs have access. The projected loss of these funds obviously contributes to administrative resistance to this change. Some addiction treatment programs are housed within psychiatric care facilities with even less attention to tobacco use.
Limited Treatment Resources
Available treatment resources—especially coverage for tobacco dependence treatment medications—often are limited for tobacco-dependent staff and patients. This is especially problematic for patients who may have limited income and are underinsured or uninsured. In the general population, psychosocial behavioral therapy alone can be as effective as medications alone in the treatment of tobacco dependence (APA 2006). However, there is a much greater likelihood of receiving only medications for tobacco dependence treatment. Integrating psychosocial tobacco dependence treatment into addictions treatment is an effective way to overcome some of the financial issues. For example, psychosocial treatment interventions in addiction treatment programs commonly address multiple drugs for any individual because other drugs (including tobacco) are triggers for the primary addiction. Integrating smoking cessation into routine addiction psychosocial treatment helps the primary addiction and does not require additional billing specific to tobacco dependence to the insurance company. As with other multiple addictions, charges for psychosocial treatment are bundled so that programs address multiple problems under the primary substance use disorder. Many inpatient programs either do not have tobacco dependence treatment medications on their pharmacy formulary or the options are very limited. Outpatient programs are more reliant on the patient’s health care benefits or willingness to pay out of pocket for these medications. Although the cost of over-the-counter nicotine replacement still is less than the cost of a carton of cigarettes, most patients still perceive that this out-of-pocket cost is too high and feel entitled to benefits covering those costs—even if they are not covered.
Over the past 10 years, many addiction treatment agencies have begun to better address tobacco dependence and have benefited from program-level interventions (Stuyt et al. 2003). One organization doing these health services interventions—the University of Medicine and Dentistry of New Jersey (UMDNJ) Tobacco Dependence Program—has helped many addiction treatment programs incorporate evidence-based tobacco dependence treatment into ongoing practice. In some cases, these programs have adopted a “motivation-based treatment” model to address tobacco dependence, which does not require abstinence by the patient, but all patients who are tobacco dependent get screened, assessed, and offered some type of treatment.
Although addiction treatment programs use urine toxicology screens and breathalyzers to screen for alcohol and other drugs, most do not screen for tobacco use with a carbon monoxide (CO) meter. The CO meter is a good measure of tobacco smoking exposure and can be used as an effective tool to motivate patients to seek tobacco dependence treatment (Steinberg et al. 2004).
Education and other motivational enhancement interventions can help less motivated patients to incrementally increase their commitment to quit. For example, information about health risks, wellness interventions (stress management, nutrition, and exercise), Stage II Recovery, available medication and other treatments, local and online Nicotine Anonymous meetings, and other community treatment resources (e.g., State-supported Internet sites and telephone quit lines) can immediately help motivate some individuals. Others may save this information for a later quit attempt. More motivated patients can aim for tobacco abstinence and be effectively treated when psychosocial and medication treatments are blended into the “treatment as usual.” Program-level interventions include staff training, policy changes, and, in some cases, establishing smoke-free grounds.
An initial health service research study has found that the UMDNJ program intervention can be effective in addressing tobacco dependence at the residential treatment program level, and another more rigorous health services study funded by the National Institute on Drug Abuse (NIDA) currently is underway to study this approach in the context of three community-based treatment programs within the NIDA Clinical Trial Network. The UMDNJ Tobacco Dependence Program co-leads this project and provides consultation and training to the programs. The consultation follows the steps outlined in the Textbox below.
Developing a leadership team with a game plan is a necessary first phase of the program intervention. Through that process the organization’s “motivational level” for addressing tobacco can be better determined. Meaningful change requires local champions of the change process. Resources of time and money are needed. Paradigm shifts are required, and staff training is essential. Because tobacco dependence is insidious in most addiction treatment programs, the leadership team should include representatives from the whole organization (i.e., administration, staff, union, housekeeping, security, grounds, etc.). Some system changes include modifying standard intake forms to include a comprehensive tobacco dependence assessment, including tobacco on the treatment planning forms, providing patient education literature, posting pro-wellness posters and no-smoking signs, and starting local Nicotine Anonymous groups. Other changes can include developing policies specific to tobacco use, labeling smoker’s charts, changing the name of “smoke breaks” to just “breaks,” not allowing staff members to smoke with patients, and providing nicotine replacement therapies or other Food and Drug Administration–approved medication for smokers on the inpatient units and possibly at other levels of care.
When implementing tobacco-related policy changes, it is helpful to ensure that such changes are not solely perceived as losses (e.g., we have all just lost our right to smoke). It may be helpful to provide a pleasant alternative during the transition. Individual programs should come up with strategies that work for them. One program, for example, replaced smoke breaks with “popcorn breaks,” with the agency providing free popcorn.
Tobacco-dependent patients should have the resources available (including trained staff) to help them quit, and patients and staff members who do not smoke should not be exposed to the toxins of ETS. There are clear barriers to addressing tobacco use and dependence, but there also are effective ways to address these barriers and promote the integration of evidence-based tobacco dependence treatment into addiction treatment programs.
The addiction treatment community as a whole now has an opportunity to denormalize tobacco use for the field by tailoring traditional tobacco control strategies to the unique issues of the addiction treatment and recovery community. Denormalization of tobacco use includes making smoking behavior not the norm and providing education about the health risks of tobacco products and the activities of the tobacco industry (e.g., Truth Campaign [Thrasher et al 2004]).
Although tobacco control strategies have effectively denormalized tobacco use in the general population (Hammond et al. 2006), these strategies have not targeted people with substance use disorders. Tobacco control efforts within the addiction treatment and recovery community could help the field to recognize and manage tobacco dependence as any other substance use disorder. Denormalization strategies in this setting would include assessing and treating tobacco dependence in treatment programs, maintaining smoke-free buildings and grounds, eliminating the sale and advertisement of tobacco products, improving understanding of the impact of smoking in the home on the children of people in recovery, and perhaps revealing how the tobacco industry may target people with other addictions (many of their ads link alcohol and tobacco). Targeted mass media campaigns have been effective in reducing tobacco use in the general population, and opportunities exist to develop a media campaign for the addiction treatment and recovery community. The leaders of Alcoholics Anonymous, Bill W. and Dr. Bob, were both smokers and died of tobacco-caused diseases before the health consequences and addictive nature of tobacco use were fully recognized. Undoing the “normalization of tobacco” that has occurred within the addiction treatment and 12-Step community for the last generation will need input from everyone involved in the treatment, prevention, and recovery community.
Tobacco dependence is one of the most common addictions among people with alcohol and other drug addictions—and a leading cause of morbidity and mortality in addiction treatment programs. Now is the time for addiction treatment programs to better address tobacco dependence at the clinical, program, and system levels. Many programs have been successful at doing so. Then there are real and perceived barriers to address, but as with recovery from any substance, the first step is to acknowledge the need for change. There are then many successful ways to begin and support that change.