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INTEGRATING
TOBACCO EDUCATION & TREATMENT
INTO SUBSTANCE USE TREATMENT
A Manual for Substance Use Treatment Providers
INTEGRATING TOBACCO EDUCATION & TREATMENT
INTO SUBSTANCE USE TREATMENT
A Manual for Substance Use Treatment Providers
Developed by
Institute for Health and Recovery
349 Broadway
Cambridge, MA 02139
Tel. (617) 661-3991
TTY (617) 661-9051
www.healthrecovery.org
Acknowledgements
This manual is the result of the work of many people over a period of several
years. We have listed them here and give them our thanks.
Staff of the Institute for Health and Recovery who assisted in planning, editing and
writing the manual:
Janet Smeltz
Caryn Kauffman
Cherie Rankin
Julie Netherland
Rebecca Budner
Norma Finkelstein
Emily Davis
Jacob Sievers
Louise Katz
Andrea Cote
Rebecca Fischman
Steve Lucasi
Lia Casale
Rebecca Dobrzynski
Center for Tobacco Prevention and Control, Division of Preventive and Behavioral
Medicine, University of Massachusetts Medical School:
Ted Purcell
Beth Ewy
Laura Robidoux
Esther Kamiri
Lori Pbert
Supporters at the Massachusetts Department of Public Health, Bureau of Substance
Abuse Services:
Sarah Ruiz
Deborah Klein Walker
Carolyn Castro Donlan
Karen Pressman
Michael Botticelli
CENAR Members, member programs, and Nicotine Replacement Therapy Pro-
grams, 1994–2011, for their courage and leadership in addressing tobacco use.
Supporters at the Department of Public Health, Massachusetts Tobacco Cessation
and Prevention Program:
Harriet Robbins Donna Warner
Staff at the Massachusetts Tobacco Cessation and Prevention Program Smokers’
Helpline:
Janet Van Ness Alice Miele
Tobacco Dependence Program (New Jersey):
Dr. John Slade, in memoriam
Abby L. Hoffman
Diane Lindberg
Bernice Order-Connors
Martha Dwyer
Jacqueline Schreiber
Table of Contents
Skills & Principles of Treating Nicotine Addiction User’s Guide ........................... 1
Introduction .................................................................................................................. 3
Background ............................................................................................................. 3
Philosophy, Description, and Use of the Manual ................................................. 4
The Challenge ......................................................................................................... 5
I. Addressing Nicotine Addiction in Recovery ........................................................ 7
II. Tobacco 101: Overview of Health Issues .............................................................. 11
A. Public Health Concerns .................................................................................... 11
B. The Benefits of Quitting .................................................................................. 21
III. Overview of Nicotine Addiction & Treatment ................................................... 24
A. Nicotine is an Addictive Substance ................................................................. 24
B. Interventions & Treatment for Nicotine Dependence .................................... 27
C. Nicotine Replacement Therapy (NRT) ............................................................ 32
D. Pharmacological Treatment for Nicotine Dependence: Zyban ...................... 34
E. Pharmacological Treatment for Nicotine Dependence: Chantix.................... 35
F. Assessment of Nicotine Dependence .............................................................. 37
G. The Stages of Change ....................................................................................... 39
H. Principles of Counseling/Support for Nicotine Dependence Treatment ....... 45
I. What Does It Take to Quit Smoking Successfully? ......................................... 47
J. Relapse Management ....................................................................................... 51
K. Reaching Clients Where They Are ................................................................... 56
IV. Integrating Education, Assessment, & Treatment of Nicotine Dependence into
Substance Use Treatment Programs .......................................................................... 64
A. Administrative/Program Issues ...................................................................... 64
B. Staff Issues: Points to Consider ....................................................................... 71
C. Boards of Directors: Issues to Consider ........................................................... 74
D. Integrating Nicotine Addiction Treatment into Substance Use Treatment
Programs .......................................................................................................... 74
V. Appendices.......................................................................................................... 85
A. Policy & Program Development: Staff Discussion Questions ........................ 85
B. Health Education Handouts ........................................................................... 89
C. Assessment Tools ............................................................................................ 96
D. Counseling Approaches ..................................................................................103
E. Stage-Based Strategies .................................................................................... 109
F. Understanding and Treating Nicotine Dependence ....................................... 119
G. Exercises/Handouts for Client Education & Staff Education ....................... 126
H. Resources for Information and Materials ....................................................... 133
VI. References .......................................................................................................... 141
1
Skills & Principles of Treating Nicotine Addiction
User’s Guide
This user’s guide offers suggestions for getting the most out of the manual, and
references the sections where you can find materials pertinent to the topics listed
below. We hope this gives you a good starting place from which to become familiar
with the manual, appendices and resources.
Target Audiences
New staff orientation Boards of Directors* Program managers Clinicians Case managers
For all of these groups, start by reviewing the follow-ing chapters and/or sections of chapters: I, II-A 1, 4–6 IV-A 2: Tobacco Guidelines IV-B For clinicians/case managers, in addition to above: Chapters II-B; III, IV-D, and all Appendices.
* Boards of Directors: also see IV.C. “Boards of Directors: Issues to Consider”
Getting Started with Tobacco Education and Treatment Activities
Integrating tobacco issues into existing groups
Chapter II-A sections 4-6; IV-D section 6; Appendices, especially B
Planning an education group
Chapter IV-D 6; Appendix B; Appendix F, Tobacco Quiz
Running a treatment group
II-B; III-A, C–K; Appendices C–E, G
Reaching clients in the precontemplation stage
III-G; III-H; Appendices E, F
Staff training
Interactive exercises to use in staff meetings/trainings
Appendix A: All Handouts Appendix D: Decisional Balance Appendix G: Beliefs/Values Clarification Appendix G: Tobacco Quiz
Policy and Program Issues
BSAS compliance / policy orientation
IV-A IV-B
How to implement new policies into your program
IV-A
Steps to becoming a tobacco-free program
IV-A 3
Dealing with resistant staff members
IV-B
2
Tobacco Treatment Information and Evidence—Based Practices
Understanding nicotine addiction
III-A Appendices D, E, F
Treating nicotine withdrawal symptoms Pharmacological approaches Other approaches
III-A; Appendices C-F Appendices D, E
Stage-based interventions
III-G Appendix E
Increasing motivation to consider quitting smoking
III-G, III-H Appendices D, E
3
Introduction
Background
Tobacco use was historically an accepted part of recovery culture both in sub-
stance use treatment programs and in Alcoholics Anonymous and Narcotics Anon-
ymous meetings. Hazy blue smoke and overflowing ashtrays were ever-present.
Smoking was generally seen as a bad habit but a necessary one, and clients were
routinely counseled to take care of alcohol and other drugs first. It was assumed
that quitting tobacco use too soon might jeopardize recovery and, over time, that
people would quit naturally on their own, or not.
Since the mid-1980s, accumulating research and experience has begun to chal-
lenge these assumptions and beliefs. Research is showing that quitting smoking
does not jeopardize recovery (Sees & Clark, 1993); that smokers also addicted to al-
cohol and opiates may be at increased risk of relapse if they continue to smoke
(Stuyt, 1997); that the benefits of smoking cessation may extend to opiate addiction
recovery as well (Frosch, Shoptaw, Nahom, & Jarvik, 2000); and that treatment for
heroin, cocaine, or alcohol addiction might be more effective if it included concur-
rent treatment of tobacco addiction (Taylor, Harris, Singleton, Moolchan, &
Heishman, 2000). In addition, a large morbidity and mortality study showed that
“tobacco-related diseases are the leading cause of death in patients previously treat-
ed for alcoholism and/or other non-nicotine drug dependence” (Hurt et al., 1996, p.
1102).
In 1994, the Massachusetts Department of Public Health, Bureau of Substance
Abuse Services (BSAS) began to address tobacco use and nicotine dependence with-
in the substance use treatment delivery system through a new initiative. This initia-
tive later became known as the Tobacco, Addictions, Policy and Education Project
(TAPE Project) of the Institute for Health and Recovery. Basing its approach on the
work of the New Jersey program, Addressing Tobacco in the Treatment and Preven-
tion of Other Addictions (later the Tobacco Dependence Program), directed by the
late Dr. John Slade, the TAPE Project targeted systems change and capacity-building
through staff training and policy development and implementation.
The underlying objectives of the initiative have been to promote increased
awareness of the importance of addressing nicotine dependence during substance
use treatment, and to provide the technical assistance treatment programs need in
order to begin incorporating smoke-free policies and interventions for nicotine de-
pendence, including education, assessment, and treatment. In 2004, with the re-
lease of the BSAS Tobacco Guidelines, consistent policies and assessment,
education, and treatment components are in place across all modalities, and the
TAPE Project is assisting with implementation.
4
The Council to End Nicotine Addiction in Recovery (CENAR), also formed in
1994, is a provider group with representation from BSAS and the Department of
Public Health’s Massachusetts Tobacco Cessation and Prevention Program (MTCP).
CENAR has served a vital role in advising the work of the TAPE Project and guiding
BSAS tobacco policy initiatives. Members meet every other month to address nico-
tine addiction issues statewide as well as in their own programs.
The work of the TAPE Project has been supported by and linked with MTCP ser-
vices. MTCP resources made it possible for substance use programs to refer staff and
clients for help, through telephone counseling, a statewide network of treatment
programs, and a website. The work of MTCP changed norms about tobacco use in
Massachusetts through public education and anti-smoking media campaigns, and
staff and clients in BSAS programs had their awareness and interest in quitting in-
creased.
In 1999, a tobacco treatment specialist certification program was developed with
the support of MTCP at the Center for Tobacco Prevention and Control, Division of
Preventive and Behavioral Medicine, University of Massachusetts Medical School.
Many BSAS treatment providers have taken the prerequisite course, “Basic Skills for
Working with Smokers,” now an on-line course, and some have completed the certi-
fication process.
Among Massachusetts adults in the general population, current smoking rates
are 16% (CDC, 2010). Informal surveys in Massachusetts treatment programs, across
modalities, indicate that rates of smoking among clients entering treatment can be
as much as four to five times higher. In Massachusetts, 77% of adult smokers want
to quit completely, and 61% tried to quit smoking at least once in the past year
(Massachusetts Department of Public Health, 2010). While these numbers may not
be representative of clients in early recovery, they do increase as people remain
clean and sober. Tobacco addiction is now viewed as a chronic and treatable condi-
tion, characterized by relapse, for which effective treatments are available, includ-
ing pharmacotherapy, counseling, and social support.
Philosophy, Description, and Use of the Manual
This manual has been a joint endeavor among the Bureau of Substance Abuse
Services, the Institute for Health and Recovery and the Center for Tobacco Preven-
tion and Control, Division of Preventive and Behavioral Medicine, University of
Massachusetts Medical School, funded through the Massachusetts Department of
Public Health. The philosophy and principles of the manual encompass the follow-
ing points:
In providing holistic treatment to clients with substance use disorders, in-
clude tobacco/nicotine issues as part of treatment planning
5
Addictions counseling skills already in use can be applied to helping clients
achieve and maintain recovery from nicotine addiction
Breaking the silence on tobacco dependence plants the seed for future quit
attempts
Change is possible and incremental
Any step forward is a cause for celebration
This manual will be helpful in setting up and enhancing comprehensive services
for nicotine addiction treatment and recovery. Comprehensive services encompass
clinical skills for treating tobacco but also include a focus on the following areas:
Review of the challenges to addressing tobacco use, and the rationale for
doing so
Creating and implementing program policies
Roles of administration, boards of directors, and clinical staff
Special health issues for substance abusing clients
Creation of office systems and practices which institutionalize tobacco
treatment
Modality-based suggestions for integrating tobacco education, assessment,
and treatment
Included in this manual are suggested discussion topics for staff meetings as well
as handouts and exercises that can form the basis for a client group. Feel free to
make copies of the handouts and worksheets and distribute them. Begin by ensuing
staff review and discussion, because staff buy-in is key to integrating nicotine de-
pendence treatment.
The Challenge
In 1994 one of the founding members of CENAR, the director of a men’s residen-
tial program, described how the only staff turnover he had in his program was due
to lung cancer. This is a sobering reality for those of us who work in the alcohol-
ism/addictions treatment field: we have seen many of our colleagues and former
clients recover from alcohol and other drug use and live dynamic lives dedicated to
service, helping others, and making a difference, only to die from tobacco-caused
illnesses. This substance, overlooked for so long, has had a devastating impact on
our field. But it is also a chronic, treatable addiction that is complex and character-
ized by relapse. We know how to treat addiction. Our field has always offered hope,
help, understanding and resources to those suffering with drug dependencies.
6
Many substance use treatment programs are now see treating nicotine dependence
as part of that mission.
In sixteen years, the treatment system has changed: most sites are smoke-free;
programs have integrated tobacco education, assessment, and treatment; and many
staff and clients have addressed their tobacco addiction and quit smoking. People
are more open to examining the role of tobacco in their lives and its impact on
treatment.
This manual is designed to help all programs become familiar with the options
and opportunities for treating nicotine dependence, and provide assistance for or-
ganizational movement forward on the Stages of Change. It is our hope that Skills &
Principles of Treating Nicotine Addiction will contribute to more discussion and
greater awareness, and that the included resources and materials will be helpful to
substance use treatment providers.
141
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