For decades, staff and patients in substance abuse and mental health treatment programs routinely used tobacco, despite growing public awareness of its addictive and noxious qualities.  In the 1980s the first voices in the modern treatment professions began to say that there's something wrong with this picture.  Since then, the treatment professions nationwide have been going through a paradigm change, often with considerable pain and turmoil.  Old tenets believed to be self-evident, such as "you can only quit one thing at a time," have turned out to be fallacies.  New findings, such as the fact that half of all alcoholics die prematurely of smoking-related diseases, have shaken up the complacent.  Rapid advances in research have uncovered striking links between tobacco smoking, alcohol/drug addiction, and major mental illnesses such as depression and schizophrenia.  Nearly half of all cigarettes sold are smoked by people who have a mental disorder, and smoking substantially reduces the effectiveness of many medications prescribed to treat mental illness.  As more Americans quit, continued smoking is becoming a marker for other substance addictions and/or mental illness.  Today, more and more substance abuse and mental health treatment facilities require staff to show no evidence of tobacco use at work, and nicotine cessation is becoming an integral part of 21st century treatment. 

The movement to integrate nicotine cessation into treatment is spearheaded by New Jersey, which already mandates it statewide, but its advocates are everywhere.  Unhooked.com webmaster Marty N. audited a nicotine workshop for treatment professionals in Oakland CA in June '02 and posted this report together with copies of selected program materials.*

Report from a Workshop to Integrate Nicotine Cessation into Chemical Dependency and Mental Health Treatment. June 5, 2002.

Oakland pediatrician Cathy McDonald, medical director of a residential drug treatment facility for teenagers, spearheaded the drive to bring the facility into the nicotine-free era, and now heads a county-funded agency, the Alcohol Tobacco and Other Drug (ATOD) Network.  McDonald and other treatment professionals led this four-hour workshop for substance abuse and mental health professionals and put together a binder of materials, including the items reproduced below.

Program Materials: Table of Contents [PDF]

Following the Pioneers: Addressing Tobacco in Chemical Dependency Treatment, by Abby L. Hoffman and John Slade, MD. Journal of Substance Abuse Treatment, 1993.  [PDF]

Written a decade ago, this seminal article outlines eight reasons why addiction treatment providers cannot ignore tobacco addiction, and 12 critical stages in the transition to a smoke-free environment. 

Handout: Compelling Reasons to Address Tobacco/Nicotine Dependence During Treatment for Alcohol and Other Drugs.  By the ATOD Network.  [PDF]

Panel Discussion: Staff share their experiences in implementing nicotine-free policies in treatment (1998). [PDF]

Although some staff resisted the change, most felt relieved at ending the hypocrisy inherent in appealing to patients to abstain from addictive, harmful drugs while maintaining silence on smoking. And patients have been supportive.

Hazelden Institute: Nicotine Addiction is Associated with Use of Alcohol and Other Drugs (1999)  [PDF]

Nicotine Craving and Heavy Smoking May Contribute to Increased Use of Cocaine and Heroin.  NIDA Note, Oct. 2000.

Alcohol and Tobacco, NIAA Alert (1998)

Smoke Screen, by Bernice Order-Connors LSCW, CADC, CPS, Professional Counselor Dec. 1996.[PDF]

The greatest barrier to treating nicotine dependence comes from staff, not from clients.  However, the addictions counseling profession must address the issue or see more of its recovering clients follow the tragic fate of AA co-founders Bill W. (cigarette smoker, died of emphysema) and Dr. Bob (cigar smoker, died of throat cancer).

Summaries of Current Research.  From The Nicotine Challenger, Winter 1998.  [PDF]

Mortality Following Inpatient Addictions Treatment, by Richard D. Hurt MD et al., JAMA 1996 [excerpt] [PDF]

Researchers followed a group of more than 800 persons who had been admitted to a county inpatient treatment facility at the Mayo Clinic in Rochester MN between 1972 and 1983.  Death certificates were obtained for more than 200.  About half of these died prematurely of diseases related to smoking; about a third died prematurely of diseases related to drinking; the remainder of other causes.  The authors conclude that nicotine dependence treatment is imperative in alcoholism treatment. 

New Residential Licensure Standards Establish Parity for Tobacco.  (New Jersey, 1999) [PDF]

Every residential addiction treatment facility in the state must treat tobacco addiction on a par with other substance addictions.  Includes tobacco in the list of substances which, when used chronically, constitute chemical dependency. 

A Clinical Practice Guideline for Treating Tobacco Use and Dependence, a JAMA Consensus Statement, by a U.S Public Health Service medical panel.  JAMA June 28 2000. [PDF]

All health care providers have an ethical obligation to address tobacco use by their patients.  Tobacco use is a chronic disease for which effective treatments are available.  The article outlines clinical methods and pointers for medical interventions to reduce tobacco use. 

Information from Your Family Doctor.  Smoking Cessation in Recovering Alcoholics:  Fiction Versus Fact.  American Academy of Family Physicians handout, 1998.  [PDF]

Facts: smoking is a bigger issue for recovering people than others.  Quitting smoking does not lead to relapse and can improve sobriety.  Smoking is the leading cause of death among alcoholics in recovery.  You CAN quit smoking and drinking at the same time.  Most people in recovery want to quit smoking and have tried.  Using tested methods and social support, and perseverance, people in recovery can quit smoking and stay quit.

Prospective Evaluation of Three Smoking Interventions in 205 Recovering Alcoholics:  One-Year Results of Project SCRAP-Tobacco, by John Martin et al., Journal of Consulting and Clinical Psychology, 1997 [PDF]

Alcoholics with more than three months' abstinence and heavy smoking habits were exposed to three different kinds of tobacco cessation programs.  After a year, all three methods proved about equally effective, and the rate of relapse to alcohol use was 4 per cent.  Length of abstinence from alcohol made no difference to success in smoking cessation. 

Smoking and Mental Illness, a Population-Based Prevalence Study, by Karen Lasser MD et al, JAMA Nov. 2000 [PDF]

Analyzing data from a nationwide mental health survey done in 1990-92, the authors find that persons with mental illness are about twice as likely to smoke as other persons, but have substantial quit rates.  Persons with a currently active mental disorder consumed 44 per cent of all the cigarettes smoked in this nationally representative sample. 

Treating Nicotine Addiction in Patients with Psychiatric Co-Morbidity, by Michael P. Resnick, in Nicotine Addiction: Principles and Management, C. Tracy Orleans MD and John Slade MD, eds. 1993. [PDF]

Psychiatric patients are more likely to be smokers.  Institutions typically use cigarettes as a tool to control psychiatric patients.  Many psychiatric patients want to quit and demand smoke-free environments.  Professional licensing standards increasingly require it.  Experience with smoking cessation in institutional settings is described.

Tobacco Cessation Among Patients With Depression, by Lirio S. Covey PhD, Primary Care Sept. 99 [excerpt] [PDF]

People with major depression are more likely to become chronic smokers and to have serious difficulty quitting.

Suggested Articles on Smoking and Mental Illness (handout, author?) [PDF]

Smoking Cessation During Pregnancy (Am. College of Obstetricians and Gynecologists bulletin, Sept. 2000, and related materials.  [PDF]

Intentions to quit smoking in substance-abusing teens exposed to a tobacco program, by Catherine A. McDonald MD MPH, Journal of Substance Abuse Treatment 2000. [PDF]

At intake to a residential substance abuse program, nearly all teens were smokers, but nearly all felt that the facility should help them quit. Desire to quit immediately increased at program completion.

Tobacco's Toll:  Implications for the Pediatrician, by American Academy of Pediatrics 2001. [PDF]

Smoking among youth is on the rise, particularly among low-income populations.  Early onset of smoking predicts long-term addiction and difficulty quitting.  Nicotine is a psychoactive drug and addiction can set in after as few as 100 cigarettes.  Teens who start smoking are more likely to develop depression, and vice versa. There are serious medical consequences from exposure to environmental smoke.  The pediatrician can and should address the issue at every opportunity.

Web links listed in the program materials:

The Tobacco Dependence Program.  New Brunswick NJ.  Founded by John Slade MD, pioneer advocate for integrating nicotine cessation into substance abuse treatment.

NIDA Research on Nicotine.  Numerous research articles and commentaries, particularly on interaction between nicotine and other addictive drugs.

American Psychiatric Association's Practice Guideline for the Treatment of Patients with Nicotine Dependence. 

US Surgeon General's Quick Reference Guide for Clinicians: Treating Tobacco Use and Dependence.

Youth and Tobacco

Advocacy for tobacco policy and funding issues: American Lung Association

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