Barriers and Solutions to Addressing Tobacco Dependence in Addiction Treatment Programs Douglas M. Ziedonis, M.D., M.P.H.; Joseph Guydish, Ph.D., M.P.H.; Jill Williams, M.D.; Marc Steinberg, Ph.D.; and Jonathan Foulds, Ph.D. Despite the high prevalence of tobacco use among people with substance use disorders, tobacco dependence is often overlooked in addiction treatment programs. Several studies and a meta-analytic review have concluded that patients who receive tobacco dependence treatment during addiction treatment have better overall substance abuse treatment outcomes compared with those who do not. Barriers that contribute to the lack of attention given to this important problem include staff attitudes about and use of tobacco, lack of adequate staff training to address tobacco use, unfounded fears among treatment staff and administration regarding tobacco policies, and limited tobacco dependence treatment resources. Specific clinical-, program-, and system-level changes are recommended to fully address the problem of tobacco use among alcohol and other drug abuse patients. KEY WORDS: Alcohol and tobacco; alcohol, tobacco, and other drug (ATOD) use, abuse, dependence; addiction care; tobacco dependence; smoking; secondhand smoke; nicotine; nicotine replacement; tobacco dependence screening; tobacco dependence treatment; treatment facility-based prevention; co-treatment; treatment issues; treatment barriers; treatment provider characteristics; treatment staff; staff training; AODD counselor; client counselor interaction; smoking cessation; Tobacco Dependence Program at the University of Medicine and Dentistry of New Jersey obacco dependence is one of to the other. The common genetic vul­ stance use was considered a potential the most common substance use nerability may be located on chromo­ trigger for the primary addiction. What Tdisorders and a leading cause of some 2 (Bierut et al. 2004; True et al. led to the decision to defer to primary morbidity and mortality in addiction 1999; See also the article by Grucza and care for the treatment of tobacco treatment programs (American Psychiatric Bierut in this issue). dependence? This paper will attempt to Association [APA] 2006; Ziedonis and Despite the existence of effective, answer these questions and to make rec­ Williams 2003). Not surprisingly, people evidence-based nicotine dependence ommendations for addressing tobacco who successfully maintain abstinence treatments, tobacco dependence is com­ use in addiction treatment programs. from alcohol and other drugs often will monly ignored in addiction treatment prematurely die from tobacco-caused programs. Why has tobacco dependence diseases such as coronary artery disease, treatment not been routinely integrated Integrating Tobacco chronic obstructive pulmonary disease, into addiction treatment programs? Dependence Treatment lung cancer, etc. (Hurt et al. 1996). What are the barriers? Interestingly, 100 at the Clinical, Program, Multiple biological, psychological, and years ago the treatment of alcohol, opi­ and System Levels social factors account for the high co­ ates, and cocaine problems included occurrence of alcohol and tobacco treating tobacco dependence (Hoffman Addiction treatment professionals dependence, including genetic evidence and Slade 1993). Addiction was perceived eventually recognized that co-occurring showing that people with genetic vulnera­ as a unitary problem, and the use of either mental illness and addiction needed to bility to one disorder also are vulnerable the primary substance or any other sub­ be addressed in the context of addic- 228 Alcohol Research & Health Tobacco Dependence Treatment in Addiction Treatment Programs tion treatment programs. Likewise, mem­ ing, other program-level interventions try to help a patient quit smoking–– bers of this field are beginning to recog­ include developing models that integrate sometimes as a result of their own guilt nize that there also is a need to inte­ the treatment of alcohol and tobacco and shame about their own smoking. grate tobacco dependence treatment dependence, staff training on assessing In the authors’ clinical work and role as across the continuum of substance abuse and treating tobacco dependence, and trainers to other professionals, staff treatment and prevention services. continuous quality improvement on this members who smoke often support Improved health services interventions topic. Broader system-level interven­ smoking with their patients as their for tobacco dependence are needed at tions include increasing collaboration way to promote a better “therapeutic the clinical, program, and system levels between health and behavioral health alliance.” Although spending nontreat­ (Stuyt et al. 2003). Clinical-level providers, developing policy changes to ment time with patients can be positive change requires better screening and promote addressing tobacco, and pro­ (such as taking walks, sharing meals, assessment of nicotine dependence and viding financial support for tobacco etc.), engaging in addictive behaviors the inclusion of tobacco dependence in dependence treatment. with a patient is inappropriate and the treatment plan. Staff training is This article reviews commonly per­ unhelpful for recovery. Smoking with necessary and an important first step to ceived barriers to addressing tobacco and patients also normalizes tobacco addic­ address attitudes, skills, and knowledge. health services interventions that can help tion and even enhances its value as a Staff who traditionally treated “alcohol addiction treatment programs better therapeutic event. An early first step dependence only” have adapted their recognize and treat tobacco dependence. in program change can include policies skills and knowledge to treat other co­ to restrict staff smoking with patients. occurring substance use disorders such This policy change promotes the addic­ as marijuana or cocaine addiction. A Barriers tion professional’s role in promoting similar transformation could occur for health and recovery instead of reinforc­ co-occurring alcohol and tobacco In addition to program culture and ing the use of substances to manage dependence. In addition to staff train- financial barriers to treating tobacco feelings and cope with stress. dependence, staff attitudes, skills, and Providing tobacco-dependent staff knowledge all influence the lack of with the resources, support, and encour­ DOUGLAS M. ZIEDONIS, M.D., M.P.H., attention given to tobacco in addiction agement for their own tobacco depen­ is a professor and chair, Department of treatment programs. Staff attitudes set dence treatment is important for their Psychiatry, University of Massachusetts the tone as to whether tobacco depen­ health, their family’s health, and the Medical School, Worcester, Massachusetts. dence will be addressed; tobacco- patient’s health. In addition, employers dependent staff often are the most have recognized the value of having JOSEPH GUYDISH, PH.D., M.P.H., is an resistant to change (Bobo and Davis nonsmoking staff. Health care costs assistant adjunct professor, Medicine and 1993; Asher et al. 2003; Williams et al. are 40 percent higher for smokers than Health Policy, University of California, 2005; Hurt et al. 1995). Treatment nonsmokers. In addition, employees San Francisco, California. wisdom discourages major life changes who smoke spend about 18 days a year during early recovery for fear of relapse, on smoking breaks, cost a company JILL WILLIAMS, M.D., is an associate and the treatment culture has accepted drug plan about twice as much, and professor, Department of Psychiatry, that “quitting tobacco” would be a are absent from work 26 percent more University of Medicine and Dentistry major life change––although quitting often than nonsmokers (Tobacco Free of New Jersey (UMDNJ) Robert Wood other substances simultaneously is not Oregon 2003). More employers are Johnson Medical School; and the (Sussman 2002; Joseph et al. 2002). recognizing that tobacco use in the UMDNJ School of Public Health workforce reduces productivity and Tobacco Dependence Program, New Staff Attitudes and Tobacco Use increases costs, and, as a result, some employers have changed their hiring Brunswick, New Jersey. About 30 to 40 percent of addiction practices and policies regarding MARC STEINBERG, PH.D., is an assistant treatment staff in community-based employee smoking. More employers professor, Department of Psychiatry, programs are tobacco dependent are helping staff who smoke to quit but (Bernstein and Stoduto 1999) com­ also are only hiring nonsmoking staff. UMDNJ Robert Wood Johnson Medical pared with about 60 to 95 percent of School, New Brunswick, New Jersey. patients (APA 2006; Lasser et al. 2000; Lack of Training JONATHAN FOULDS, PH.D., is an associate Richter et al. 2004); 22 percent of the professor and director, Tobacco Dependence general population (Centers for Disease Staff members in addiction treatment Control and Prevention [CDC] 2005); settings often receive little or no train­ Program, UMDNJ Robert Wood Johnson and 3 to 5 percent of physicians, den­ ing in treating tobacco dependence. Medical School; and the UMDNJ School tists, and dental hygienists (Goldstein Fortunately, addiction counselors know of Public Health Tobacco Dependence et al. 1998; APA 2006). Staff members how to treat other addictions, and the Program, New Brunswick, New Jersey. who smoke most likely are not going to learning curve is quick and often very Vol. 29, No. 3, 2006 229 Tobacco Dependence Training