Smoking: The “Ignored” Addiction

It has been difficult to watch treatment centers allow smoking clients to continue their devastating addiction while in treatment. Some clients, juveniles and adults, first started to smoke while in treatment.  Special smoking areas (e. g. “butt huts” and “smoking pits” etc.) are set up and become the place where the “action” is.  Clients want to be in on the action.

In 1984, Onsite Workshops of South Dakota, where I was Medical Director, discovered one of the secrets of their positive outcomes.  Onsite went smoke free that year for therapists and for participants in the Living Centered Program.  Things happened. We learned so much over those years including:  “You can’t heal what you can’t feel and you can’t feel what you medicate”.  Nicotine is a subtle but strong medicator of emotions.  This is most apparent after it has been withdrawn.

In 2001, as a member of the advisory board of a prominent addiction treatment center, we began an intervention regarding their lack of a non-smoking policy. The facts were, that as an addiction treatment facility, they were not documenting or treating nicotine dependence. They were actually aiding and abetting their smoking patients.  Special arrangements allowed smokers to continue their nicotine addiction while in treatment for their other addictions. The center agreed it didn’t make sense.

With careful step-wise planning at the executive, administrative and clinical staff levels, good progress toward a nicotine addiction treatment program was made.  Patients joined in with the hope that recovery from this addiction was also possible.  Unfortunately, the policies and procedures they instituted those first two years were withdrawn when new ownership took over the facility.

There are general policies and activities that can be instituted and result in a smoother transition into a smoke free therapeutic environment.

Here are two that can help:

Smoking cessation activities are not separated from the core program.  Nicotine addiction becomes an additional item on the client’s problem list. It integrates just fine with the non-smoking client’s work in the groups.  The only unique aspects might be a Nicotine Addiction Support Group in the evening and a “Nicotine Funeral Service” and a “Dear John Letter” exercise.  Non-smoking clients join in and identify with the exercises.

Addiction theory is used throughout.  Just as in other addictions the client’s opponent is not the agent, the alcohol, the meth, or the nicotine.  Clients are frequently surprised to find that their actual opponent is that pesky, immature, acting-out pleasure center in the middle of their own brain.  The focus is not on the cigarette.  It takes the principles of “train your brain” and mindfulness.

How do you know how to treat nicotine addiction?  If you work in the addictions field you already know how to treat nicotine addiction.  You already know how to recognize and confront denial, anxiety, fear and rationalization. You already know how to address anger, withdrawal, guilt and depression.  You already know how to guide someone toward capturing their self-esteem and spirituality, to heal traumatic wounds and to depend on their own self-care.

Self-esteem/self-worth is a motivating force.  The importance of emotions and supportive relationships in dealing with recovery from nicotine addiction needs to be stressed.  Blending smoking cessation with the other presenting issues can be complimentary and add to the overall dynamics of the healing process. This approach adds to, rather than interferes with, the existing program.  Therapy became more potent, accelerated and successful.

Most smoking cessation programs are outpatient and not very intense time-wise.  The client is left to his or her own care in early withdrawal.  Thus, there are many programs that deal with and accept frequent relapses.  To help minimize or even avoid this early on, it is probably desirable that an intense “kick-off” weekend and daily attendance at Nicotine Anonymous meetings be instituted.  Each professional and each facility needs to design their own approach.

There is a need for quality care for the nicotine addict.  Reality says that a person is not clean and sober until they recover from cigarette smoking.  That statement sure does shake up those AA/NA members who still smoke.

The addiction treatment fields, as well as many other healthcare programs,  admit that they mostly ignore nicotine addiction in their patients/clients.  A Health and Human Services panel has stated:

“The failure to treat tobacco use, the chief cause of preventable disease and death, constitutes an inappropriate standard of care”.

So what can be done?   It is almost impossible to expect a busy treatment facility to suddenly decide to become non-smoking.  Many treatment programs have debated the risks and benefits of implementing a smoking cessation program.

Nicotine dependence deserves recognition as the life, and quality of life, threatening illness it is.

Health care professionals need to embrace the concept that smoking cigarettes and other manifestations of nicotine dependence is a treatable addiction.  Other addictions required that positive acceptance before they received serious attention.

So what can be done?  Here are a few suggestions.

The first steps can be fast and easy.  They are awareness steps:

• Perhaps, do no more than physically mark the outside of the smokers medical record;
• List nicotine addiction on the problem list;
• Code out the inside of the patients’/clients’ chart with whatever DSM-IV designation(s) are appropriate: 305.90 Nicotine Dependence, 292.9 Nicotine related disorders, 292.0 Nicotine withdrawal
• Train staff to use self-worth exercises in regard to the client becoming a new non-smoker.
• Investigate and clarify the emotional aspects of smoking.  This is a good area for experiential expression of feelings by the patient/client.
• Point out the importance of “publicizing” their recovery from smoking.  The more often they say, “I don’t smoke!” the deeper not being a smoker becomes imprinted into their brain.
• Encourage the client/patient to refrain from statements that identify them as a smoker.  “I am trying to quit…” or “I haven’t smoked for five days” keeps them in the mindset of a smoker.
• Suggest uplifting exhilarating lifestyle changes that will occur in recovery from nicotine addiction.  Greater enjoyment of the  the five senses, increased stamina, freedom from an every 20” pre-occupation.
• Integrate some of these concepts and tasks into treatment plans where appropriate:
• Reading assignments can be given out.
• Checklists are good for Group and Nicotine Anonymous discussions and feelings groups topics.
• Use a “Dear John” letter and have a  “Funeral” as experiential group exercises.  Smokers and non-smokers benefit when they can formally say goodbye to their addictions.
• Build appropriate sections of the aftercare plan to address potential threats to nicotine abstinence.
• Visibly display some of the excellent smoking cessation literature around the office or the facility.
• Add more to what is presently being done about nicotine addiction.

One of the first awareness steps is to start coding charts with the diagnosis of nicotine dependency.  It may increase motivation and awareness farther for therapists and MD’s to add the second part of the coding… “Nicotine Dependence…305.10…not treated, not improved”

And what are the obstacles to getting started?

Here are a few, there are more:

• There is anger and resistance on the part of the smoking staff and the younger adult and adolescent patients who smoke.
• Administration worries that potential referrals/referents may not call
• Clinical staffs worry that smokers in withdrawal will fall apart, decompensate and become too pre-occupied to do the work.  (Medical detox for other drugs is not changed, except for the heavy smoker who may need short term nicotine replacement therapy).
• Clinical staffs believe a different approach and too much time is needed to treat nicotine addiction.  They feel it will deter from the primary programs.  (Actually, when feelings formerly medicated by nicotine begin to surface, therapy is enhanced.)
• Outcomes are not inspiring. The positive outcome in many smoking cessation programs is less than 50% at three months and many times less than 30% at one year. One recent study paid smokers to stop smoking. The researchers presented their statistics thusly, “Paid smokers (n = 442) had a three-fold increase in the success rate at 12 months, 14.7% in the paid/teaching group versus 5% in the non-paid/teaching group (n = 436).”  Therefore 80.3% of those who were getting paid were unsuccessful and 95% of the control group were unsuccessful (New England Journal of Medicine, February 12, 2009).

So, rather than have these uninspiring results deter us from doing therapy for nicotine addiction, we need to jump in and offer help to those thousands who try and fail every day.
In the United States nicotine use is diminishing, but there are still 45 million smokers out there.  Eighty percent of adult smokers wish they could quit (Gallup). Health care providers who decide to treat nicotine addiction vigorously will have a huge base of “customers” to draw upon.

Dealing with nicotine addiction can increase the excitement, challenge and satisfaction therapists get from their work.  Individual psychotherapists can benefit their community with an active approach to nicotine addiction. Having an active primary group and a fun aftercare group can become a desirable part of the neighborhood.

It will take a major shift in professional common sense for us to stop ignoring nicotine addiction.

Meanwhile, a crushed, processed, broad dry leaf wrapped in a specially treated easy-burning paper will continue to maim and kill…

Good Luck to all of us…

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