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Smoking for Behavioral Health Patients

Smoking for Behavioral Health Patients

It has only been recently that addiction treatment programs have seriously considered the issue of smoking by its patients. Historically, smoking had not been a concern, especially when compared to other drugs of abuse which were their patients’ identified problems. Fifty years ago, patients in addiction treatment were permitted to smoke in lounges, group therapy sessions, and lectures. In fact, the only place where they were prohibited from smoking was in bed! Even more recently, patients at some facilities are given smoke breaks—how’s that for rewarding smoking behavior? It was also not uncommon for adolescents in treatment to be given smoke breaks, but because of the potential risk of adolescents having their own matches or lighters on their persons, their cigarettes were lit by staff, which is actually a violation of the law!  


Part of the early resistance to dealing with smoking was that most alcohol and drug counselors smoked and smoking was endemic among both active and recovering alcoholics. Sixty to 75 percent of patients in alcoholism treatment are tobacco dependent and about 40 to 50 percent are heavy smokers (Hughes, 1995). The drug most abused by people with schizophrenia is tobacco, at three times the rate of the general population (Hughes, Hatsukami, Mitchell, & Dahlgren, 1986). But even as smoking by alcohol and drug counselors gradually lessened over the years, other beliefs and perceptions did not change, and are currently still held by many.


Smoking has always been regarded differently from other drugs primarily because of the lack of immediate consequences, which is interesting because we have the same situation today with marijuana. Smokers will not get into legal problems as a result of their smoking. They will not get arrested for domestic violence, sexual battery or impaired driving as alcoholics might; they are not likely to steal or rob as some heroin or stimulant addicts might to get money to purchase their drugs; they are not likely to break into a pharmacy for prescription drugs. This obstacle presented by the lack of proximate consequences is best illustrated in our past ineffective smoking prevention efforts for adolescents for whom getting lung cancer thirty-five years from now just did not compute.


The other belief which seems to persist is “You can’t stop more than one thing at a time.” First of all, this is not what the literature indicates (Gulliver, Kamholtz, & Helstrom, 2006). Secondly, clinicians who hold this view would not apply the same thinking if the other drug patients were using—as opposed to the drug for which they were receiving treatment—was cannabis or a benzodiazepine. If patients have diagnosable disorders to alcohol, stimulants, and opioids, this belief would require us to choose one of the three “because you cannot stop more than one substance at a time.” The research has demonstrated that it is actually easier to stop all of the substances at one time (Gulliver et al., 2006).


One concern of providers is that if they begin treating tobacco and electronically delivered nicotine, it will negatively impact census. There is evidence that it does cause a slight decline in census originally and then rebounds to what it was before or even higher (Sharp, Schwartz, Nightingale, & Novak, 2003). If we decided to proceed with this twenty years ago, this would be much more of a concern. However, in the interim there have been so many restrictions placed on where smokers can smoke that they have become used to restrictions and expect them.


In another study, many patients who smoked when entering addiction treatment said that they wanted to stop smoking (Gulliver et al., 2006).


A practical question is, “Why should we embark on such an effort?” Here are some reasons.  


The Problems that Result from Smoking


  • It is estimated that each year more people die as a result of smoking and second hand smoke than all the people who die from the use of alcohol, heroin, cocaine, AIDS, car accidents, homicide, suicide, and World War II.
  • Chronic obstructive pulmonary disease (COPD) and lung cancer—as well as cancers of the mouth, tongue, and larynx (and interestingly of the kidneys)—are very common results of long-term smoking.
  • Smoking interferes with the effects of psychiatric medications. In one study of acute psychiatric patients, those who stopped smoking were readmitted for acute psychiatric treatment at a lower rate than those who continued smoking (Kobayashi et al., 2010). 
  • Some survey participants with current or past histories of the mood/anxiety, alcohol or drug disorders quit smoking during the three-year period between initial and follow-up interviews. Compared with participants with such histories who continued to smoke at or near their initial intensity, the people who quit were less likely to have current diagnoses of their disorders at the follow-up interview (NIH, 2006).
  • Smoking interferes with neurocognitive recovery in alcoholics for the first eight months of abstinence.
  • Smoking is associated with relapse to drug of choice (Gulliver et al., 2006) and this is especially true when the delivery system of the drug of choice was smoking (e.g., crack cocaine).
  • Participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs (Prochaska, Delucchi, & Hall, 2004).
  • In general smoking has a significant negative impact on productivity—think of the frequently needed smoke breaks—and health care utilization which might indirectly have an impact on the cost of insurance and even wages.
  • Premature birth and low birthrate in pregnant women who smoke is common.




Why is it Difficult to Quit?


  • Many people in recovery from other addictions will tell you that it was more difficult to stop smoking than to stop their drug of choice.
  • Smoking is the most efficient and therefore the most compulsive route of delivery of a drug.
  • The effects of the psychoactive substance on the brain occur within eight to ten seconds when smoking.
  • People dependent on heroin may dose themselves every four hours or so to forestall withdrawal. Smokers may dose themselves multiple times an hour or even a minute, every time they take a puff.
  • Smoking is not viewed with the same seriousness as addiction to other drugs.



How to Succeed with Recovery from Nicotine Addiction


  • We have to change the the thinking and the language. The term “smoking cessation” results in continuing the artificial separation between smoking/nicotine and other addictive drugs. We do not talk about “heroin cessation” or “alcohol cessation.”
  • We have to approach this from a recovery from substance use disorders perspective.
  • Many years ago at a meeting of recovering alcoholic physicians, the speaker (also a physician), said, “If you are still smoking, you are not in sober!”
  • Smoking in treatment (even if outside) should be tolerated no differently than cannabis use in the facility by someone with a severe alcohol use disorder. The problem is not the drug of choice, it is a matter of addiction and developing strategies to learn to avoid reliance on psychoactive substances with which to cope.
  • Tobacco use disorder and nicotine use should be reflected in the the assessment, the treatment plan, and the progress notes as with any other addictive drug.
  • Some mandatory psychoeducation about smoking for all patients should be required with optional groups for those interested in quitting but smoking should still be prohibited for those not interested in quitting.
  • Smokers should be afforded pharmacotherapy and behavioral drug help for withdrawal, just as we do with the other addictions.
  • A recent research finding is that smokers who quit all at once are more successful than those who try to quit gradually.




Some Thoughts about the Use of Electronic Nicotine Delivery Systems (Vaping)


  • For some reason, the the DSM-5 changed the diagnosis of Nicotine Use Disorder to Tobacco Use Disorder even though the addictive substance remains nicotine (APA, 2013).
  • As to the question of whether vaping is safer than smoking, the answer probably is yes because there is no combustion in vaping.
  • As to whether it is safe, not enough is known at this time to answer that question, but it reminds me of a sarcastic, related statement that it is safer to shoot yourself in the head with a .22 than a .45 because a .22 makes a smaller hole!
  • It might be of interest to you that electronic nicotine delivery systems are the new book of business for the tobacco companies.




My question to you, or more precisely my challenge is, where are you with smoking for behavioral health patients, and if you are concerned, as you should be, what are you prepared to do about it?







American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. 

Gulliver, S. B., Kamholtz, B. W., & Helstrom, A. W. (2006). Smoking cessation and alcohol abstinence: What do the data tell us? Alcohol Research and Health, 29(3), 208–12. 
Hughes, J. R., Hatsukami, D. K., Mitchell, J. E., & Dahlgren, L. A. (1986). Prevalence of smoking among psychiatric outpatients. American Journal of Psychiatry, 143(8), 993–7.
Hughes, J. R. (1995). Combining behavioral therapy and pharmacotherapy for smoking cessation: An update. NIDA Research Monograph, 150, 92–109. 
Kobayashi, M., Ito, H., Okumura, Y., Mayahara, K., Matsumoto, Y., & Hirakawa, J. (2010). Hospital readmission in first-time admitted patients with schizophrenia: smoking patients had higher hospital readmission rate than non-smoking patients. International Journal of Psychiatry in Medicine, 40(3), 247–57.
National Institutes of Health (NIH). (2006). Alcohol use and alcohol use disorders in the United States: Main findings from the 2001–2002 national epidemiologic survey on alcohol and related conditions (NESARC). Retrieved from http://pubs.niaaa.nih.gov/publications/NESARC_DRM/NESARCDRM.pdf
Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144–56. 
Sharp, J. R., Schwartz, S., Nightingale, T., & Novak, S. (2003). Targeting nicotine addiction in a substance abuse program. Science and Practice Perspectives, 2(1), 33–9.