12 Steps to Success: Tobacco Cessation for Your Addiction Treatment Center
As addiction treatment providers, our job is to help our clients achieve recovery and wellness. But more often than not, we overlook a crucial behavior that can significantly impede this journey. Our clients are not dying from their addiction. They are dying from cigarettes.
Our ability to lessen the effects of tobacco use is no different among people with substance use disorders than it is with any other population. We know from research and experience that people with these disorders want to quit, that intervention strategies work, clients respond well to both NRT (nicotine replacement therapy) and counseling, and that cessation is possible. And yet, behavioral health settings rarely address tobacco use.
The smoking prevalence rate of individuals with alcohol use disorders is updwards of 70%, and other drug users smoke at rates anywhere from 49% to 98%. I have worked in residential addiction and psychiatric treatment centers where clients were allowed to smoke during treatment. Staff often took smoke breaks with clients, and at times, smoking was seen as a reward for doing well in treatment. Tobacco cessation is not a common term we hear in our field and I encounter a lot of skepticism and resistance from my peers. This is often due to the misconception that smoking cessation doesn’t work with this population, is ineffective, or may negatively impact treatment. In these conversations I do my best to talk about the fact that tobacco use increases the likelihood of relapse, and that if you treat tobacco use while also treating the other addiction, the client is 25% more likely to abstain from the original substance for which they entered treatment.
I shared my experience working with the Center for Dependency, Addiction, and Rehabilitation (CeDAR) on an October 17 webinar, Smoking & Addiction Treatment: Debunking the Myths and Becoming Tobacco-Free, to help mental health and addiction organizations become a tobacco-free campuses. During the webinar, I shared the 12 Steps to Success to becoming tobacco-free. Here, I outline those steps to implement an effective tobacco control program:
Step 1. Convene a tobacco-free committee – This is important to do very quickly! Gathering advocates within your agency with a high level of medical knowledge to promote this policy will help immensely for this big and scary change. Invite someone from every division within your workplace and include a client or alumnus from your program.
Step 2. Create a timeline – Every facility is different, so some programs will take longer than others to implement this change. It is important to create the timeline to track the progress of your efforts. Identify what it is you want to accomplish, and the smaller steps you will need to take to get there.
Step 3. Craft the message – What are you going to do? How are you going to talk to individuals about this? Who are the people you need to talk to? You want to think about every group and person involved to make sure you create the correct messaging. This includes staff, clients, referral sources, and everyone in between.
Step 4. Draft the policy – Very clearly write down the message, the rules, and how you will handle individuals who do not comply with the policy. Try and think of common scenarios so you can outline specifics. It’s important that people understand what is allowed and what is not. The Behavioral Health and Wellness Program’s Tobacco Free Toolkit for Community Health Facilities is an excellent resource for policy examples.
Step 5. Clearly communicate your intentions – Going back to messaging, you want to make sure that everyone is on board with not only how this change is happening, but also WHY you are doing it. There are a multitude of educational handouts and videos that you can share with staff and clients.
Step 6. Educate staff and clients – Going back to step 3, 4, and 5, the education of your staff and clients is important in both policy and messaging along the way. The Behavioral Health and Wellness Program has a variety of resources to help.
Step 7. Provide tobacco cessation services – Do this in a two-prong approach: provide education and resources to staff members and then cessation services to clients. The good news is that many insurance plans now cover a number of evidenced-based treatments, including bupropion, varenicline, NRTs, and counseling services. Additionally, each state has a quit line, 1-800-QUIT-NOW, that can provide free counseling, and sometimes NRTs, for those interested in quitting.
Step 8. Build community support – People are going to walk to the edge of a tobacco-free campus and use tobacco there. It is important to inform your neighbors about your new policies. Think about local pharmacies and their supply of NRT. What conversations do you need to have with them and what is your relationship/referral process?
Step 9. Launch the policy – Part of launching is counting down and making announcements. This is a lot of work, so be prepared to ensure that everyone is aware of the new policy date.
Step 10. Monitor the policy & respond to challenges – Continue to meet with your committee after you implement the change. It is important to do this because it will help keep the momentum and establish the change within the organization. This is a really hard step to maintain (just like staying off tobacco after quitting!).
Step 11. Case Study – Keep records of all the work you did before, during, and after going tobacco-free and create a case study from the lessons you learned along the way.
Step 12. Disseminating Innovation – Use your case study and share it with your network of care providers. Helping out the entire system will help everyone in the long run.
These steps were incredibly helpful for us. Contrary to common concerns, CeDAR did not see a decline in admission rates after going tobacco-free. We saw the same number of people seeking care who identified themselves as tobacco users as we did before the change. And probably the most exciting results from our efforts was that after implementation, 100% of both clients and staff that were current smokers said they reduced their overall use of tobacco and 50% of clients intended to stay tobacco free after discharge (up from 6%).
While these results are exclusive to CeDAR, they are not uncommon. Agencies across the country have successfully implemented tobacco-free programs, with similar outcomes. If you work at an addiction treatment agency, I challenge you to join the other organizations that have become leaders in the field of addiction and tobacco use.
Already a leader? I encourage you to share your thoughts and success stories and whether any of the 12 steps have worked for your agency.