On June 5, I attended a four-hour Nicotine Dependence Treatment Training organized by the Alameda County Alcohol, Tobacco and Other Drug (ATOD) Network.  Approximately 40 people filled a fifth-floor conference room at the beautiful new Alameda County Behavioral Services Center at 2000 Embarcadero on the Oakland waterfront.   

All the participants except myself were employed as treatment providers with substance abuse or mental health treatment programs.  Continuing Education Credits were offered. I met several friends there, including staff from the 14^th Street detox facility where Marylou B. and I had presented LifeRing last month.  I also met a Kaiser counselor from the San Francisco CDRP who conducts quit-smoking work there.  I met the medical director and a staff member from the Haight-Ashbury Free Clinic.  Perhaps a dozen treatment programs were represented.  I had copies of the LifeRing meeting schedule with me, and handed them out on the slightest provocation.  They met with ready acceptance; one counselor from a clinic connected with Highland Hospital asked for a handful of extras.   

The purpose of the workshop was to train providers to include nicotine cessation treatment in their substance abuse and mental health treatment programs.  The main presenter was Dr. Cathy McDonald, who spearheaded the process of building nicotine cessation into the program of Thunder Road, a 50-bed substance abuse treatment program for teenagers. 

Also among the speakers were physicians from Garfield Neurobehavioral Center, a long-term inpatient facility for patients disabled by severe mental disease.  They described the process of changing patients’ “smoke breaks” into “patio breaks” and gradually detoxing patients from nicotine.  

The written materials included numerous stories of chemical dependency and mental health treatment programs that had gone through the process of broadening their services to include treatment for nicotine addiction in their offerings.  In this county, it appears that the major CD and MH programs are in the process of integrating nicotine cessation into their programs, so that nicotine addiction is treated on a par with other substance addictions.  A number of the most well known institutions have already done so. There was the sense of a growing nationwide initiative in this direction. 

The presentation offered some material that was familiar to me, such as the fact that tobacco is by far the deadliest of all the addictive drugs.  Tobacco kills more people in the US each year than alcohol, cocaine, crack, heroin, homicide, suicide, car crashes, fires, and AIDS combined:  about 450,000 deaths per year.    

Tobacco takes a particularly heavy toll among alcoholics.  In a study at the Mayo Clinic, about half of all alcoholics who had taken part in an alcoholism treatment program eventually died of causes related to smoking.  The average age at death was substantially less than normal life expectancy. 

The presenters and materials also did a good job rounding up in one place the research showing that people can quit smoking and drinking at the same time.  Quitting smoking not only does not harm recovery from drinking, it improves it:  studies show that people who quit smoking when they quit drinking end up having fewer relapses and enjoying a longer sobriety. 

 I also learned some things that were completely new to me, namely that smoking substantially reduces the effectiveness of many psychoactive medications used in the treatment of mental illness, so that dosages for smokers must be increased to compensate, and lowered again when the patients quit. 

Workshop participants and materials emphasized several reasons why treatment programs in the chemical dependency and mental health area were motivated to include nicotine cessation in their program.  One factor was patient demand.  Even among severely disabled mental patients the general reaction against tobacco in this country over the past 20 years has found an echo, and the physicians at the Garfield facility reported that a number of patients approached them to ask for a smoke-free treatment environment.  A similar pattern obtained at Thunder Road: the clients were generally supportive of the move to a smoke-free program, and the main resistance came from some tobacco-using staff members and from parents.  About one third of patients in a hospital study, reported in the materials, spontaneously wanted to work on quitting nicotine along with their other drugs, and this portion doubled once the facility itself became smoke-free. 

Another important motivating factor for many providers was the feeling that the failure to address nicotine addiction undermines and sabotages their abstinence message to the patients.  Providers put major effort into trying to teach patients to abstain from drugs that provide immediate gratification but create long-term harm.  To stand silent in the face of nicotine use, providers felt, is hypocritical and lowers the credibility of the whole treatment rhetoric.   

Providers also observed that smoking in treatment programs puts former smokers at risk of nicotine relapse and in some cases leads people to commence habitual nicotine use.  Garfield physicians described instances in which staff actually held cigarettes for severely disabled patients so that they could smoke, and purchased cigarettes for patients out of the agency budget.  It took them a while to ask “what’s wrong with this picture?" 

Providers in the substance abuse treatment setting also became aware over time that smoking cessation did not bring with it the feared rash of additional relapses.  Studies at first found no discernible difference in outcomes for patients who quit smoking as well as drinking.  Then as more different facilities assessed and reported their outcomes, studies began to show that quitting smoking actually conveys a recovery advantage: drinkers who quit smoking do better at staying off the drink than those who keep puffing.   

Many providers are also concerned by the heavy tobacco mortality rate among recovering alcoholics and drug users.  It seems less than compassionate and ultimately demoralizing for staff to devote their lives to treating addiction to certain substances that kill their patients, only to watch the patients fall victim to another far more deadly addictive substance that treatment ignored.  The example of Bill W. and Dr. Bob, the co-founders of AA, is cited in the written workshop materials.  Bill W., long a chain-smoker of cigarettes, spent his last years in a wheelchair hooked up to an oxygen tank, and died of emphysema.  Dr. Bob, a cigar smoker, died of throat cancer.   

 The written materials at the workshop contain several referrals to Nicotine Anonymous, but the presenters and participants showed little overt enthusiasm for this approach.  Historically, AA and NA have missed the boat on smoking, and the 12-Step approach to nicotine dependence has not caught on, at least not in this area.  Segregating nicotine cessation from other substance addictions also misses the main point that the presenters were trying to get across: that nicotine cessation needs to be integrated into substance abuse and mental health treatment efforts.   

Interest and enthusiasm in this roomful of providers was mainly for methods that used behavioral and motivational enhancement techniques in combination with pharmacological aids such as the patch and bupropion (wellbutrin, Zyban).  Of course, this segment of the treatment profession is not the Old Guard.  There were some gray heads, but the average age must have been less than 30.  These people are at the cutting edge, defining the shape of things to come.  One got a sense of purpose and movement from these people, not the mood of drift and demoralization that I have felt among other gatherings of treatment providers.   

Among the most interesting points in the material were the stories of the pioneers who initiated the movement toward nicotine education in the substance abuse treatment settings, such as Dr. John Slade of New Jersey.  In almost every instance, these initiatives met at first with considerable hostility and misunderstanding.  But perseverance pays off: New Jersey today leads the nation in requiring smoking cessation and smoke-free facilities in all residential chemical dependency treatment facilities in the state. 

As one of the authors in the written materials noted, the cultural legacy of the 12-Step movement exerts a heavy drag on progress in this area.  Many substance abuse treatment staff, as we all know, are products of the 12-step recovery culture, which in many cases means that they are active nicotine addicts in the pre-contemplation stage.  If it was good enough for Bill W. and Dr. Bob, it’s good enough for them.  At so-called model 12-step treatment programs, such as the one described in the recent Beyond the Influence by Ketcham (reviewed at http://www.unhooked.com/booktalk/beyond_the_influence.htm), tobacco awareness consists of admonishing patients to pick up their cigarette butts.

The modern pioneers of the smoke-free movement in the substance abuse treatment industry faced and still face enormously difficult challenges in opening the door to scientific knowledge regarding nicotine addiction.  Among these nicotine challengers are the natural allies of science-based, secular alternatives to the 12-Step approach in recovery generally.  If these treatment providers are open to secular methods for smoking cessation – and this crowd appeared overwhelmingly so -- they’re already halfway to acceptance that the same methods have validity for alcohol and other drug cessation.  It isn’t news to them that their patients need other choices in addition to 12-Step.

Hockey great Wayne Gretzky summed up the secret of his scoring success on the ice this way:  “Skate to where the puck is going next.”  In substance addiction and mental health treatment, it looks like nicotine cessation is where the puck is headed.  It’s true that these professions are lagging perhaps 10 or 20 years behind other healing professions and behind public tobacco consciousness generally.  But, better late than never. 

-- Marty N.  6/11/02