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 Resources for Addiction Treatment Staff

University of Massachusetts Medical School, Center for Tobacco Prevention and Control The Center is actively engaged in a wide range of tobacco-related research, clinical treatment services, technical assistance, and professional education programs. Available at: www.umassmed.edu/behavmed/tobacco

University of Medicine and Dentistry of New Jersey (UMDNJ) Tobacco Dependence Program The UMDNJ provides training programs on tobacco dependence (including a 5-day comprehensive training program) as well as program consultation, technical assistance, research, and clinical service. Resources on their Web site include information on how to obtain their “Drug Free is Nicotine Free” manual for program change. Available at: www.tobaccoprogram.org

Mayo Clinic Nicotine Dependence Center Education Program This is an intensive, 5-day course focusing on the skills needed to effectively treat tobacco dependence. Available at: http://mayoresearch.mayo.edu/mayo/research/ndc_education/tts_certification.cfm

Association for the Treatment of Tobacco Use and Dependence (ATTUD) The ATTUD is dedicated to the promotion of and increased access to evidence-based tobacco treatment and has developed standards for competencies for tobacco treatment specialists. Many of the national training centers follow these competencies. The ATTUD standards are available at: www.attud.org

ACT Center for Tobacco Treatment, Education, and Research of the University of Mississippi The ACT Center, a program of the University of Mississippi Medical Center School of Dentistry, provides training, education, treatment, and research, including a comprehensive tobacco treatment specialist training program. Available at: http://actcenter.umc.edu/

University of Wisconsin Medical School, Center for Tobacco Research and Intervention (UW-CTRI) The UW-CTRI program provides extensive training and technical assistance to help put tobacco cessation research into practice. Available at: www.ctri.wisc.edu and www.medscape.com/viewprogram/3607 (CME online)

The Addiction Technology Transfer Center of New England Funded by the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, the Addiction Technology Transfer Center of New England is offering an online course on the cessation of tobacco use: “Tobacco Cessation Treatment: Best Practices.” Available at: www.attc-ne.org/education/courses/ann262.html

Center for Substance Abuse Treatment Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. Rockville, MD: Department of Health and Human Services publication no. (SMA) 05-3992. Substance Abuse and Mental Health Services Administration, 2005. This includes several lengthy sections on assessing and treating tobacco dependence. Available at: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.74073

U.S. Department of Health and Human Services The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General, 2006. Available at: www.surgeongeneral.gov/library/secondhandsmoke/

230 Alcohol Research & Health Tobacco Dependence Treatment in Addiction Treatment Programs

rewarding when applied to tobacco. nize that part of their role is to treat to screen, assess, and treat tobacco The lack of training for most staff tobacco dependence––and that this is dependence routinely are needed to members reflects the field’s blinders to not just primary care’s responsibility. ensure that tobacco dependence treat­ this topic––but this is changing. The They can better appreciate that tobacco ment skills are utilized (Ziedonis et al. National Association of Alcoholism use must be addressed because of the 2006). Strategies for treating patients at and Drug Abuse Counselors (NAADAC) increased morbidity and mortality all levels of motivation to quit are now offers a Tobacco Addiction among their patients. In addition, envi­ important. Effective brief interventions Specialist credentialing program and ronmental tobacco smoke (ETS) affects for addressing tobacco dependence in has a policy that “advocates and sup­ both smokers and nonsmokers. Children, less motivated smokers have been eval­ ports the development of policies and people with existing cardiac disease, uated (Steinberg et al. 2004) and may programs that promote the prevention and older adults are particularly vulner­ be useful for addressing tobacco in and treatment of nicotine dependence able to the health consequences of ETS. addiction treatment populations. on par with alcoholism and drug Many staff members are surprised to dependence” (NAADAC 2006). Some learn that tobacco use is the number Clinical Lore States offer “Tobacco Dependence one preventable cause of death in the Specialist Added Qualifications” to their United States (CDC 2001) (see Figure). Training staff members to treat tobacco certified alcohol and drug counselor More addiction treatment programs and dependence also helps change the treat­ certification programs, and many States clinicians are recognizing that address­ ment culture by correcting many of the now require mandatory tobacco training ing tobacco dependence is important misconceptions or “clinical lore” about as part of both initial and recertification for promoting wellness and recovery. tobacco––such as “tobacco is not a real for credentialed addiction counselors. All smokers should be encouraged to drug,” “it’s too hard to address all the Several national training centers provide seek tobacco dependence treatment at substances together,” and “quitting intensive face-to-face or online training some point in their recovery, and tobacco will definitely worsen other and other resources (see the Textbox on addiction treatment staff can readily substance recovery.” Clearly, tobacco page 230). learn to use the evidence-based psy­ is both addictive and deadly––even if Providing staff training enhances chosocial treatments and integrate their the serious health consequences are skills and knowledge––and also changes use with appropriate medications (includ­ not immediate and do not disrupt the attitudes. With appropriate skills and ing several over-the-counter options). patient’s life as dramatically as other knowledge, staff members often recog- System-level reminders to trigger staff substances with regard to legal, employ­ ment, 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 smok­ ing 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 Comparative causes of annual deaths in the United States. Tobacco use is the when they quit alcohol or stop alcohol number one preventable cause of death in the United States. use when their primary drug is heroin. Patients may express their own con­ SOURCE: Centers for Disease Control and Prevention (CDC), 2001. Available at: cerns that the urge to smoke will be www.cdc.gov/tobacco/research_data/health_consequences/andths.htm intolerable, withdrawal will be very dif­ ficult, quitting will affect their primary

Vol. 29, No. 3, 2006 231 recovery, and they may actually need cigarettes to help them cope with stress Steps for Addressing Tobacco Within Addiction (Asher et al. 2003). In fact, evidence Treatment Programs suggests that the opposite can occur–– that tobacco use can harm, rather than 1. Acknowledge the challenge to address the barriers and integrate the enhance, recovery from other substance solutions use by its ability to trigger other substance use (Williams et al. 2005; APA 2006). 2. Establish a leadership group and make a commitment to change Another potential barrier is that 3. Create a change plan and realistic implementation timeline some staff may believe that their patients 4. Start with easy program and system changes, including tobacco policies are just not interested in quitting smoking. As a result, the staff will not 5. Conduct staff training discuss the issue of tobacco dependence 6. Assess and document in charts nicotine use, dependence, and prior and quitting. However, many substance treatments abusers are interested in quitting smok­ 7. Incorporate tobacco issues into all patient education curriculums ing as part of recovery (Ziedonis and Williams 2003; APA 2006). Although 8. Provide medications for nicotine dependence treatment more than half of patients who smoke 9. Provide treatment and recovery assistance for interested nicotine- believe that quitting smoking will be the dependent staff hardest addiction for them to address 10. Integrate motivation-based treatments throughout the program (Kozlowski et al. 1989), there is evi­ dence that tobacco addiction can be 11. Establish ongoing communication about system changes with 12-Step treated successfully in addiction treat­ recovery groups, professional colleagues, and referral sources ment programs, both immediately and 12. Consider additional policies addressing tobacco, including smoke-free later in the recovery process. In a recent grounds meta-analytic review of randomized tri­ als of smoking cessation in substance NOTE: Adapted from Order-Connors B. Smoke screen. Professional Counselor 11(6):15–52, 1996. abuse settings, Prochaska and colleagues (2004) concluded that patients engag­ ing in tobacco dependence treatment resistance to smoke-free buildings by that allow smoking. Contrary to expec­ had better overall substance abuse some addiction treatment staff, State tations, treatment programs with treatment outcomes at 6 months after laws and requirements set by the Joint smoke-free grounds often report less treatment compared with those who Commission on Accreditation of acting out, less haggling about smoke did not engage in tobacco dependence Healthcare Organizations have changed breaks/number of cigarettes allowed, treatment. The exact best timing for an the norm to smoke-free buildings for less coercion of smokers by either peers individual patient is less clear (Joseph treatment. In addition to smoke-free or staff, no increase in the AMA dis­ et al. 2004); however, the key is to buildings, some inpatient workplaces charge rate, increased likelihood of assess and make a plan to treat tobacco (including addiction treatment programs) completed treatment, and an increase dependence at some point during treat­ have taken an additional step toward in the number of patients seeking treat­ ment and/or recovery. addressing tobacco by implementing ment (APA 2006; Williams et al. 2005; “smoke-free grounds.” This step means Hurt et al. 1995). Smoke-Free Buildings and that tobacco smoking is not allowed Other cultural milieu barriers are Resistance to Smoke-Free Grounds anywhere on the grounds of the addic­ subtle. Some programs still sell tion treatment program, rather than just cigarettes with the profits contributing Secondhand tobacco smoke poses a being prohibited in the buildings. Having to one of the few “discretionary” funds real health risk to everyone exposed to entirely tobacco-free grounds is an addi­ to which these programs have access. the smoke, and the issue is well addressed tional policy change that some States The projected loss of these funds obvi­ in the recent Surgeon General’s Report have now mandated for their treatment ously contributes to administrative on Secondhand Smoke (U.S. Department programs (see Sidebar on pp. 236– 240). resistance to this change. Some addic­ of Health and Human Services 2006). Staff members who smoke often ini­ tion treatment programs are housed The Textbox on page 233 lists the key tially oppose the “smoke-free grounds” within psychiatric care facilities with findings from this report. The need to level of program change. Program lead­ even less attention to tobacco use. provide clean indoor air has resulted in ers, administrators, or staff members policy changes to require smoke-free also may have concerns that patients Limited Treatment Resources buildings in many workplaces and will act out, have worse withdrawal, public settings, including health care leave against medical advice (AMA), or Available treatment resources––especially facilities. Although there was initial seek treatment at competing programs coverage for tobacco dependence treat-

232 Alcohol Research & Health Tobacco Dependence Treatment in Addiction Treatment Programs

tion doing these health services inter­ Surgeon General’s Summary of the Effect of ventions—the University of Medicine Secondhand Smoke and Dentistry of New Jersey (UMDNJ) Tobacco Dependence Program—has 1. Secondhand smoke causes premature death and disease in children and helped many addiction treatment pro­ in adults who do not smoke. grams incorporate evidence-based 2. Children exposed to secondhand smoke are at an increased risk for tobacco dependence treatment into sudden infant death syndrome (SIDS), acute respiratory infections, ongoing practice. In some cases, these ear problems, and more severe asthma. Smoking by parents causes programs have adopted a “motivation­ respiratory symptoms and slows lung growth in their children. based treatment” model to address tobacco dependence, which does not 3. Exposure of adults to secondhand smoke has immediate adverse effects on require abstinence by the patient, but the cardiovascular system and causes coronary heart disease and lung all patients who are tobacco dependent cancer. get screened, assessed, and offered some 4. The scientific evidence indicates that there is no risk-free level of type of treatment. exposure to secondhand smoke. Although addiction treatment pro­ 5. Millions of Americans, both children and adults, are still exposed to grams use urine toxicology screens and secondhand smoke in their homes and workplaces despite substantial breathalyzers to screen for alcohol and progress in tobacco control. other drugs, most do not screen for tobacco use with a carbon monoxide 6. Eliminating smoking in indoor spaces fully protects nonsmokers from (CO) meter. The CO meter is a good exposure to secondhand smoke. Separating smokers from nonsmokers, measure of tobacco smoking exposure cleaning the air, and ventilating buildings cannot eliminate exposures of and can be used as an effective tool to nonsmokers to secondhand smoke. motivate patients to seek tobacco depen­ dence treatment (Steinberg et al. 2004). SOURCE: U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Education and other motivational Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, enhancement interventions can help National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. less motivated patients to incrementally increase their commitment to quit. For example, information about health ment medications––often are limited tiple addictions, charges for psychoso­ risks, wellness interventions (stress for tobacco-dependent staff and patients. cial treatment are bundled so that pro­ management, nutrition, and exercise), This is especially problematic for patients grams address multiple problems under Stage II Recovery, available medication who may have limited income and are the primary substance use disorder. and other treatments, local and online underinsured or uninsured. In the gen­ Many inpatient programs either do not Nicotine Anonymous meetings, and eral population, psychosocial behav­ have tobacco dependence treatment other community treatment resources ioral therapy alone can be as effective medications on their pharmacy formu­ (e.g., State-supported Internet sites and as medications alone in the treatment lary or the options are very limited. telephone quit lines) can immediately of tobacco dependence (APA 2006). Outpatient programs are more reliant help motivate some individuals. Others However, there is a much greater likeli­ on the patient’s health care benefits or may save this information for a later hood of receiving only medications willingness to pay out of pocket for quit attempt. More motivated patients for tobacco dependence treatment. these medications. Although the cost of can aim for tobacco abstinence and be Integrating psychosocial tobacco over-the-counter nicotine replacement effectively treated when psychosocial dependence treatment into addictions still is less than the cost of a carton of and medication treatments are blended treatment is an effective way to over­ cigarettes, most patients still perceive into the “treatment as usual.” Program- come some of the financial issues. For that this out-of-pocket cost is too high level interventions include staff train­ example, psychosocial treatment inter­ and feel entitled to benefits covering ing, policy changes, and, in some cases, ventions in addiction treatment programs those costs––even if they are not covered. establishing smoke-free grounds. commonly address multiple drugs for An initial health service research any individual because other drugs (includ­ study has found that the UMDNJ pro­ ing tobacco) are triggers for the primary Solutions gram intervention can be effective in addiction. Integrating smoking cessation addressing tobacco dependence at the into routine addiction psychosocial Over the past 10 years, many addiction residential treatment program level, treatment helps the primary addiction treatment agencies have begun to better and another more rigorous health ser­ and does not require additional billing address tobacco dependence and have vices study funded by the National specific to tobacco dependence to the benefited from program-level interven­ Institute on Drug Abuse (NIDA) cur­ insurance company. As with other mul­ tions (Stuyt et al. 2003). One organiza­ rently is underway to study this

Vol. 29, No. 3, 2006 233 approach in the context of three com­ Tobacco-dependent patients should addictive nature of tobacco use were munity-based treatment programs have the resources available (including fully recognized. Undoing the “normal­ within the NIDA Clinical Trial trained staff) to help them quit, and ization of tobacco” that has occurred Network. The UMDNJ Tobacco patients and staff members who do not within the addiction treatment and 12­ Dependence Program co-leads this smoke should not be exposed to the Step community for the last generation toxins of ETS. There are clear barriers project and provides consultation and will need input from everyone involved training to the programs. The consulta­ to addressing tobacco use and depen­ in the treatment, prevention, and recov­ tion follows the steps outlined in the dence, but there also are effective ways Textbox on page 232. to address these barriers and promote ery community. Developing a leadership team with a the integration of evidence-based tobacco game plan is a necessary first phase of dependence treatment into addiction the program intervention. Through treatment programs. Conclusion that process the organization’s “motiva­ The addiction treatment commu­ tional level” for addressing tobacco can nity as a whole now has an opportunity Tobacco dependence is one of the most be better determined. Meaningful to denormalize tobacco use for the field common addictions among people change requires local champions of the by tailoring traditional tobacco control with alcohol and other drug addictions–– change process. Resources of time and strategies to the unique issues of the and a leading cause of morbidity and money are needed. Paradigm shifts are addiction treatment and recovery com­ mortality in addiction treatment pro­ required, and staff training is essential. munity. Denormalization of tobacco grams. Now is the time for addiction Because tobacco dependence is insidious use includes making smoking behavior treatment programs to better address in most addiction treatment programs, not the norm and providing education tobacco dependence at the clinical, the leadership team should include rep­ about the health risks of tobacco prod­ ucts and the activities of the tobacco program, and system levels. Many resentatives from the whole organiza­ programs have been successful at doing tion (i.e., administration, staff, union, industry (e.g., Truth Campaign [Thrasher et al 2004]). so. Then there are real and perceived housekeeping, security, grounds, etc.). barriers to address, but as with recovery Some system changes include modify­ Although tobacco control strategies from any substance, the first step is ing standard intake forms to include a have effectively denormalized tobacco comprehensive tobacco dependence use in the general population (Hammond to acknowledge the need for change. et al. 2006), these strategies have not assessment, including tobacco on the There are then many successful ways targeted people with substance use dis­ treatment planning forms, providing to begin and support that change. ■ orders. Tobacco control efforts within patient education literature, posting the addiction treatment and recovery pro-wellness posters and no-smoking community could help the field to Acknowledgements signs, and starting local Nicotine recognize and manage tobacco depen­ Anonymous groups. Other changes can dence as any other substance use disor­ Dr. Ziedonis is supported by the include developing policies specific to der. Denormalization strategies in this National Institute on Drug Abuse tobacco use, labeling smoker’s charts, setting would include assessing and changing the name of “smoke breaks” to treating tobacco dependence in treat­ (R01 DA020705, Organizational just “breaks,” not allowing staff members ment programs, maintaining smoke- Change and Nicotine Dependence to smoke with patients, and providing free buildings and grounds, eliminating Treatment; R01 DA15978–01, nicotine replacement therapies or other the sale and advertisement of tobacco Modifying Motivational Enhancement Food and Drug Administration–approved products, improving understanding of Therapy [MET] for Poly-Drug medication for smokers on the inpa­ the impact of smoking in the home on Addiction; and R01 DA015537, tient units and possibly at other levels the children of people in recovery, and Treatment of Addiction to Nicotine of care. perhaps revealing how the tobacco in Schizophrenia) and the Substance When implementing tobacco- industry may target people with other Abuse and Mental Health Services related policy changes, it is helpful to addictions (many of their ads link alco­ Administration (SAMHSA) (GS–10F– ensure that such changes are not solely hol and tobacco). Targeted mass media 0148P, Evaluation of the SAMHSA perceived as losses (e.g., we have all just campaigns have been effective in reduc­ lost our right to smoke). It may be ing tobacco use in the general popula­ National Co-Occurring Disorder State helpful to provide a pleasant alternative tion, and opportunities exist to develop Initiative Grant). during the transition. Individual pro­ a media campaign for the addiction grams should come up with strategies treatment and recovery community. that work for them. One program, for The leaders of Alcoholics Anonymous, Financial Disclosure example, replaced smoke breaks with Bill W. and Dr. Bob, were both smok­ “popcorn breaks,” with the agency pro­ ers and died of tobacco-caused diseases The authors declare that they have no viding free popcorn. before the health consequences and competing financial interests.

234 Alcohol Research & Health Tobacco Dependence Treatment in Addiction Treatment Programs

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