Nicotine dependence is an issue for both staff and client

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1 Smoke Screen By Bernice Order-Conors, LCSW, CADC, CPS Nicotine dependence is an issue for both staff and client Tobacco use and nicotine dependence have held an unusual place the in the field of chemical dependency. They have gone virtually untreated and ignored. As treatment providers, addressing this "elephant in the living room, is our challenge and our responsibility. Approximately 25 percent of the general population smokes. Among drug addicts and alcoholics, that number soars to about g0 percent. A 1996 study by Richard Hurt at the Mayo Clinic found that tobacco-caused illness is more likely to kilt drug addicts and alcoholics than complications from their other addictions. A 199l study by Burling, Marshall and Seidner at the Palo Alto Department of Veterans' Affairs found that treating nicotine dependence actually had a positive impact on the recovery of alcoholics and addicts. More studies are illustrating that the rate of clients going "against medical advice,' (AMA) is not negatively affected by integrating nicotine dependence treatment, and that sobriety is more stable for clients who are also treated for nicotine dependence. Addressing Tobacco in the treatment and Prevention of Other Addictions is a non-profit consultation service that helps New Jersey s alcohol and drug treatment programs cope with the problem of tobacco smoke pollution and nicotine addiction. The project is funded by grants from the New Jersey Department of Health's Division of Addiction Services and by the Robert Wood Johnson Foundation, in cooperation with St. Peter's Medical Center in New Brunswick. At Addressing Tobacco..., we pose the question: "If nicotine is a drug and we treat drug addiction, why aren't we treating nicotine dependence?" The answer is simple: we should. Smoke Screen appeared in the December 1996 edition of Professional Counselor magazine, published by Health Communications of Deerfield Beach, Florida and is reprinted with permission of the publisher. "The greatest barrier to treating nicotine dependence comes from staff, not from clients." At every screening and intake, questions about nicotine dependence must be included in the chemical-use history of our clients. Nicotine issues need to be part of the treatment plans for smokers. We can offer our clients education, detoxification, treatment planning and case management, including relapse prevention. Drug free means nicotine free.

2 A classic example of the effect of nicotine dependence on the chemically dependent can be found in the miraculous story of how one man struggling against alcoholism shared his experience, strength and hope with another. Together, they spawned a fellowship that has helped millions of alcoholics achieve sobriety. However, we lost both of Alcoholics Anonymous' cofounders, Bill Wilson and Dr. Bob Smith, to illnesses caused by their tobacco use. Bill Wilson gave his last World Service speech in Miami, wearing an inhalator and gasping for air. With an oxygen tank strapped to the back of his wheelchair, he was lifted to the podium. Soon after, he died of emphysema, a rare disease except among smokers. Smith, a cigar smoker, died of throat cancer. MYTHS AND BARRIERS "You can't take everything away from them at once." "No major changes in the first year." "First things first." "They're dealing with enough already." These and other commonly held misconceptions - such as concerns that clients will go AMA, or that census numbers will fall, or that taking away nicotine will be the straw that broke the camel's back - are all based on our own fears and have no basis in reality. These myths are deeply embedded in the chemical dependency field and among l2-step communities. The truth is, our clients trust our judgment when we issues beyond their primary addictions. We do this all the time. Our clients come in for a cocaine problem and we look at their alcohol and marijuana use as well. When their family members use, this also is addressed in treatment. Our experience at Addressing Tobacco... is that the greatest barrier to treating nicotine dependence comes from staff and not from clients. Perhaps it is because our field, more than any other population, is so severely afflicted with this drug dependency, that we are so ambivalent about treating nicotine dependence. Clinicians smoke and chew tobacco; spouses and family members are addicted; and administrators use. How can the "impaired professional" offer services in this area? We must address the issue of staff use of tobacco as we make a commitment to integrating nicotine dependence treatment in the treatment and prevention of other addictions. Chemical dependency prevention and treatment agencies need to acknowledge the profound impact tobacco has on the client community and look to their mission statements to insure that nicotine-dependence treatment is included. Administration must commit to integrating nicotinedependence treatment for clients and their families, in the same way we offer treatment for alcohol and other drugs of dependence. Most important, all staff use of tobacco must be addressed.

3 This begins with a clearly articulated timeline outlining the goal of becoming smoke free both indoors and outdoors, throughout the facility and its grounds. Facilities also must require that there be no evidence of tobacco use during working hours, just as they require no evidence of alcohol and drug use. Staff Recovery As a service of the Addressing Tobacco...project, I facilitate a 5-hour motivational workshop for staff members of chemical dependency treatment programs in the state of New Jersey. The purpose is to assist nicotine dependent staff members to look at their current and past tobacco use. This workshop, called "For Smokers Only" GSO), is usually held on-site at the treatment facility during work hours. It is a voluntary program available for all levels of staff. The workshop is designed to help staff assess where tobacco fits in their lives. Participants look at what purpose nicotine serves for them, where they see themselves in terms of the stages of change, and what actions they can take toward their ultimate goal of quitting. As the barrier of staff use is removed, the facility can move toward inte_ grating nicotine addiction treatment into its treatment purview. Through education and group discussion, the workshop participants examine how intricately nicotine use is woven into their lives. They tum their "barriers" into., facilitators,,, and begin to address the complex cues for smoking. A goal for disarming the cues associated with smoking is to "isolate the addiction," from the cues. This means that a smoker who is preparing to stop needs to isolate the use of nicotine from the powerful cues and behaviors associated with smoking. For example the phone rings and a smoker reaches for a cigarette before picking up the phone. In addressing this behavior, we don t ask people to throw away their phones. Instead, we isolate the using behavior (smoking) from the pleasantries associated with it (speaking on the phone). By adopting a "smoke-free, policy in the home, hundreds of triggers and cues are eliminated. The goal is to make people think about whether they really "need" that cigarette, and then begin to evaluate more realistically how much genuine pleasure they gain from their use of nicotine. When one makes one s home smoke-free in an effort to "isolate the addiction," it is often reported that consumption of cigarettes falls 50 percent or more. As people separate activities they associate with smoking from their use of tobacco, they may realize how this addiction has become a tremendous burden that takes them away from the things in life they really enjoy' One counselor recently told me she feels like a junkie in a crack house' For example, the when she takes her smoke break What continues to impress me - and frustrate so many of the people I speak with is how little recognition people give themselves for the tremendous changes they make in their nicotine use patterns on their way to quitting. We are geared to measuring addiction recovery in black or white - either using or not using. Based on Prochaska & DiClemente's stages of change model,

4 the person in the "planning/determination" stage is using. It is unrealistic to expect someone to 'Just stop" because they have knowledge or insight about their use. In conducting workshops, I repeatedly see the shame staff members feel about continued tobacco use. So many people, while still using nicotine, report the incongruent feelings associated with recognizing that they work in the field of chemical dependency and are themselves still active in an addiction. People report feeling like frauds and failures because they still smoke. They recognize this is improper role-modeling and feel it compromises their professionalism. One counselor recently told me she feels "like a junkie in a crack house" when she takes her smoke break in the corner of the courtyard at her treatment facility. While conflict is painful, it can also be a powerful motivator. Following the FSO workshop, participants receive follow-up phone calls at approximately 3 weeks, and 3, 6, 9, and 12-months. While it is satisfying to hear that someone has stopped smoking, it is also very encouraging to work with and hear from people who are making the changes necessary to stop smoking. Nicotine dependence is a cunning, baffling, and powerful addiction. We need to move away from shaming and blaming the addict, and from considering nicotine addiction as "minor/' compared to what brought someone into treatment. We need to offer the most comprehensive treatment for addiction and that includes nicotine addiction treatment. We need to start by offering support to the nicotine-dependent staff member. We need to offer options such as onsite and off-site programs to stop smoking. We need to assist in the 'establishment of Nicotine Anonymous meetings to help clients and staff recover from this addiction. Stages of Change Perhaps when we pose the question, "Where does nicotine dependence treatment fit in the chemical dependency treatment paradigm?" we can look to the stages of change model as a guide. What stage is your treatment facility in? Precontemplation- "Nicotine dependence treatment doesn't fit into our program, we have too many other issues to deal with." Contemplation- "Yes, we really need to look at this but.... Planning/Determination- "-We're developing a timeline with goals and objectives to integrate nicotine dependence treatment. We've established a committee to develop a plan, the administration at the facility supports the work of the committee, and staff and clients have a clear understanding of the time frame for going smoke-free indoors, smoke free for staff, and smoke-free for the clients and the entire grounds." Action- "We screen and assess every client and integrate nicotine addiction into the treatment plan. We offer educational groups and individual counseling. We work with clients' family members and nicotine addiction treatment is incorporated into the relapse-prevention plans for clients."

5 Maintenance- "We've been doing this work a long time. What took the rest of you so long to catch on?" We can also pose the same question to the chemical dependency treatment field as a whole, including the certification process for addictions counselors, the development of curriculum for prevention and education programs, the establishment of policy at the state departments of health, and the development of treatment protocols for the chemical dependency community. At what point will the field require that! clinicians who identify themselves as nicotine dependent become abstinent and remain abstinent? At what point will the integration of nicotine-dependence treatment be required of chemical dependency programs that claim they provide comprehensive treatment? Our experience at Addressing Tobacco tells us that the programs that are most successful in the integration of nicotine dependence treatment are those that develop a comprehensive policy and a timeline for becoming tobacco-free; are supported by their administration; understand the need to address the issue of staff use of tobacco; and provide parameters as well as support to their staff members. Our experience also tells us that it is imperative that the licensing and regulation boards direct and establish policies to guide our field, and that counselor certification require training in nicotine-dependence treatment. Comprehensive care and treatment for our clients is our ultimate goal. We need direction and a plan to achieve our mission to provide the most comprehensive care available. Bernice Order-Connors, L.C.S.W., CADC, and CPS is the clinical consultant for the Addressing Tobacco...project. She is also in private practice with Associates in Psychological Services in Somerville, New Jersey.