Integrating Tobacco Treatment and Education into Substance Use Treatment
Evidence clearly supports the need to address tobacco use by people being treated for substance use. Tobacco / Nicotine product use includes: cigarettes, cigars, pipes, smokeless tobacco, and electronic nicotine delivery systems (ENDS) including vape pens, mods, tanks, and JUULs.
- Tobacco use is associated with higher rates of relapse to alcohol and other drugs. Quitting smoking increases the odds of long-term recovery.
- As a basic treatment principle, comorbidities should be addressed together, since they can be mutually reinforcing and there is every indication smoking cessation treatment can help, not hinder, treatment for other mental health problems. (Compton 2017)
- Smoking is associated with worse symptoms and outcomes among people with behavioral health conditions, including greater depressive symptoms, greater likelihood of psychiatric hospitalization, and increased suicidal behavior.
- Smoking reduces the effectiveness of some medications, resulting in the need for higher medication doses to achieve the same therapeutic benefit.
- Continuing to smoke worsens health conditions related to Hepatitis C and HIV/AIDS.
- People with behavioral health conditions account for almost half of tobacco-related deaths every year. The most common causes of death among people with behavioral health conditions are heart disease, cancer, and lung disease- all of which can be caused by smoking.
- Smoking is far more common among people entering substance use treatment than the general population:
- 70% of smokers want to quit. Since clients present in different stages of readiness for quitting tobacco use, assessing their interest in stopping smoking on a regular basis can help facilitate change.
Integrating Tobacco / Nicotine Treatment and Education into Substance Use Treatment
- Facilitating client behavior change around tobacco use and addiction works best when relevant health and recovery messages, environmental cues, and motivational strategies are integrated into all aspects of a program.
- When all staff members help clients make connections between tobacco use and psychosocial issues such as saving money, physical health and wellness, children’s health, and strengthening recovery skills, then talking about tobacco use and recovery becomes normalized.
- Even if clients are not thinking about stopping smoking tomorrow, staff can plant seeds for change by making connections between tobacco use and its negative impact on finances, health, children’s health, and finding housing. Emphasize the benefits of quitting for recovery.
- Early in treatment, many people are not even thinking about quitting tobacco use, or quitting tobacco use feels too hard. Over time, staff can help facilitate change by providing tobacco/nicotine education and keeping the conversation about tobacco use ongoing as part of the treatment process.
- Group treatment offers many opportunities to make relevant connections between substance use recovery and tobacco recovery. Programs can offer a discrete Tobacco Awareness Group, or can integrate material on tobacco/nicotine into a variety of topics such as wellness/health, recovery skills, alcohol and drug education, and anger management.
- Suggestions for tobacco awareness groups:
- Suggestions for integrating tobacco/nicotine issues into other standard treatment groups:
- Handout: Integrating Tobacco / Nicotine Education Into Groups (suggested topics for Alcohol & Drug Education; Vocational; Health & Wellness; Pregnancy & Parenting)
- Handout: Tobacco Integration Into Groups (suggested questions)
Staff Concerns about Addressing Tobacco Use
Trying to help clients address their tobacco use when you are a smoker or concerned about integrating tobacco can be challenging and confusing, but it is possible. Areas to think about are:
- Your role as a clinician/case manager/staff member in a Bureau of Substance Addiction Services (BSAS) program
- Your own current or prior relationship with tobacco use
- Direct, factual messages you can share with clients on a regular basis.
Here are some points to consider and discuss with program directors, supervisors, & co-workers, in addition to the points listed in the overview.
- Your role: Provide integrated treatment
- BSAS is committed to integrating tobacco education and treatment into substance use treatment.
- BSAS Standards of Care (2015) require integration of tobacco/nicotine addiction in assessments, treatment planning, services and education.
- Tobacco and nicotine products are significant co-occurring addictive substances used by as many as 95% of individuals entering treatment services for substance use disorders (SUDs), vs. 14% in the general adult population.
- Examine your own relationship with tobacco
- If you are in tobacco recovery, how do you maintain your recovery?
- How do you feel about your own tobacco use? What stage of change are you in with your tobacco use?
- How does your tobacco/nicotine use affect you? (Physically? Emotionally? Financially? Socially?)
- If you are considering a change in your tobacco use, what small steps could you take at work? At home?
- Keep it Client-Focused: Messages for Clients
- If you are working with clients who have tried to quit tobacco use before, let them know it is normal and expected to make multiple quit attempts before quitting for good. Reframe past quit attempts as success stories and highlight strengths that made the client stay quit for however long it was.
- If clients are not interested in quitting, or not ready to quit, find opportunities to make connections between current tobacco use and the ways it may get in the way of other priorities and future goals.
- Use our handout, “Making Connections.” For example, what does the client know about the following important and relevant topics?
- Stopping smoking has a positive impact on maintaining recovery from other substance addictions.
- Smoking worsens co-occurring medical conditions such as HIV, Hepatitis C, and diabetes.
- Smoking interferes with how well commonly prescribed medications work (including methadone).
- Reducing exposure to second-hand smoke improves children’s and family members’ health.
- A pack of cigarettes costs as much as $11. What could you do with this money?
- Take a “health break” together – if possible, bring clients outside for a smoke-free/vape-free walk or try a meditation exercise in a group
- Develop a plan ahead of time for how to respond when clients ask about your own tobacco use.
- If we are current or recovering smokers/tobacco users, sometimes our own issues can come up when we address tobacco use with clients. This is called countertransference. Supervision is an important place to assess and talk about the feelings and issues that emerge for clinicians in our work with clients.
- Talk with your supervisor and colleagues about how to comfortably use your own experience with tobacco use to talk with clients about their tobacco use.
- Try role playing with a colleague or your supervisor to practice what to say and how to say it.
Resources to Help with Tobacco Use/Vaping Education and Treatment
For incorporating tobacco prevention and treatment into SUD treatment and prevention programs:
- Tobacco, Addictions, Policy and Education (TAPE) Project of IHR: staff training, consultation and technical assistance on education, treatment and policy issues, free to BSAS funded programs
- Our online trainings: On-PAR and Smokefree Families (at https://www.healthrecovery.org/our-work/tobacco/)
- SAMHSA has provided a national focus on integrating tobacco into substance use disorders treatment. Here are two helpful pamphlets:
- Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings: https://store.samhsa.gov/product/Implementing-Tobacco-Cessation-Programs-in-Substance-Use-Disorder-Treatment-Settings/SMA18-5069QG
- “Quitting Tobacco: Helping Your Clients to a Healthier Life”: https://store.samhsa.gov/product/Quitting-Tobacco/SMA18-5069QT
- Smoking Cessation Leadership Center: Fact sheets, Presentations and Webinars https://smokingcessationleadership.ucsf.edu/behavioral-health
- IHR's Tobacco Projects Pinterest page: https://www.pinterest.com/healthrecovery/
- IHR Resources for Tobacco/Nicotine Dependence Recovery: https://careersofsubstance.org/sites/careersofsubstance.org/files/Resour...
Help for Quitting Tobacco Use
- MA Smoker’s Helpline: 1-800-QUIT-NOW for free coaching and weeks of free nicotine patches, gum, or lozenges if medically appropriate; also at http://makesmokinghistory.org/quit-now/. New incentive programs available for people quitting menthol products and for pregnant women, and specialized programs for people experiencing substance use or mental health conditions, youth, and coaching for American Indians by American Indians.
- Smokefree.gov: free online resource offered by the National Institutes of Health. Separate help and information sections for women, teens, veterans, seniors, and Spanish speakers. https://smokefree.gov/
- Truth Initiative’s Become an Ex: https://www.becomeanex.org/ , free digital resource to help tobacco users quit
- Truth Initiative’s Quit vaping text line (for youth and young adults): Text “Quit” to 706-222-QUIT
- For Veterans: 1-855-QUIT-VET (1-855-784-8838) https://www.publichealth.va.gov/smoking/quitline.asp