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“To Dream The Impossible Dream:
Your Site CAN Go Smoke Free”
Heather C. Harlan, CRPS
ACT Missouri Prevention Conference
Lodge of the Four Seasons
Tuesday, November 18, 2014
Do you ever
feel like this?
What are you hearing about quitting
tobacco and treatment for substance use
disorders (SUD—used to call addictions)
at YOUR agency?
Learning Objectives:
• Identify research driven reasons that quitting tobacco
when quitting alcohol and other drugs IMPROVES
outcomes for treatment.
• Understand how tobacco-free workplaces improve
productivity, learning, safety and lower costs to deliver
services.
• Empower informed advocacy tobacco-free policies at
treatment centers and other health and community
sites while reviewing the ongoing journey of Phoenix
Health Programs to be 100% tobacco-free.
Upon completion of this workshop
participants will be able to…..
• Expose the myth that giving up smoking while in treatment
will lower recovery rates.
• Anticipate sources of resistance in peer and professional
treatment communities.
• Outline effective strategies to initiate smoke-free policies at
treatment centers and other health and community sites
and commit to begin the conversation at your site.
• Affirm the position that tobacco-free sites are in the best
interest of clients, staff, tax payers and our communities.
Are you a prevention or substance abuse
treatment professional who sees this
everyday at work?
Staff Break Room
And this?
Smoking tobacco long associated with
other addictions. AA Founders Dr. Bob
Smith and Bill Wilson died of tobacco
related illnesses.
Smoking rates?
18.1% of adult Americans smoke
tobacco according to CDC.
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking
About 25% of adult Missourians
smoke—the 9th highest in the nation-MO
Dept. of Mental Health
http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/
BUT . . .
•
•
•
•
--
Approx 71% of all illicit drug users smoke.
74 – 100% of patients in drug treatment
smoke.
85 – 98% of patients in methadone
maintenance treatment smoke.
70 % of HIV + patients smoke.
New York State Office of Alcoholism and Substance Abuse Services
2004 US Surgeon General’s Report—Diseases
and other Adverse health Effects for Which
Smoking is identified as a Cause
Bladder cancer
Cervical cancer.
Esophageal cancer.
Kidney cancer.
Laryngeal cancer.
Leukemia.
Lung cancer.
Oral cancer.
Pancreatic cancer.
Stomach cancer.
Abdominal aortic aneurysm.
Atherosclerosis.
Cerebrovascular disease.
Coronary heart disease.
Copd.
Pneumonia.
Reduced lung function among
infants.
Respiratory disease in childhood
and adolescence.
Fetal death and stillbirth.
Reduced fertility.
Low birth weight.
Pregnancy complications.
Cataracts.
Hip fractures.
Low bone density.
Peptic ulcer disease.
ENDEMIC?
“Although cigarette smoking is endemic among
illicit drug users, drug abuse treatment
programs rarely encourage smoking cessation
and often discourage it.”
http://archives.drugabuse.gov/DirReports/DirRep204/DirectorReport7.html
pandemic [pan-dem-ik]
Adjective
• 1.(of a disease) prevalent throughout an entire
country, continent, or the whole world; epidemic
over a large area.
• 2.general; universal: pandemic fear of atomic
war.
Noun
3.a pandemic disease.
Endemic [en-dem-ik]
adjective, Also, endemical
1.natural to or characteristic of a specific people or
place; native; indigenous: endemic folkways;
countries where high unemployment is endemic.
2.belonging exclusively or confined to a particular
place: a fever endemic to the tropics.
Noun
3.an endemic disease.
Tradition views have been . . .
• Tobacco is less harmful.
• It’s too stressful to stop tobacco at the same time and will
make treatment for other drugs less effective.
• A smoke-free treatment environment will keep people from
seeking treatment for other drugs
• People seeking help for other drugs don’t want to quit
tobacco.
• We can’t ask clients to quit when so many of our staff use
tobacco.
• It will cause people to relapse in their SUD and/or their
mental health problems.
“Wonder what the
Man with the
Yellow Hat and the
research say about
that?”
Substance use disorders=Chronic illness
Similar to diabetes, asthma, hypertension.
http://www.drugabuse.gov/publications/drugs-brains-behavior-scienceaddiction/treatment-recovery
Many substance abuse treatment programs
are based on PATT interventions:
1. Personal experience of the counselor
“Here’s what worked for me.”
2. Anecdotal evidence
“I heard of someone who . . . .”
3. Tradition
“We’ve always done it that way.”—often 12
step programs.
4. Time
“We have a 21 day program.”
No seemed to be able to answer the
questions
“But how well does it work?”
“What’s the number of people it helps and
how does it help them?”
How many approach a chronic health
condition this way?
Doc,
Just DO
something.
I don’t care
how well it
works—just
DO something.
Sometimes . . .
. . . Our common sense approach about what
we think will work is right.
. . .Sometimes, it’s not.
Family member:
1973—severe broken leg. Treatment after surgery= total bed
rest for a week.
2012—hip replacement and was walking on it the next day.
What changed?
Someone thought to test the theory “total bed rest” is best.
Now we know walking as soon as possible helps lymph circulate
• Lowers risk of infection
• Promotes healing.
What changed? Research.
Traditionally?
Treating substance use disorders in an
environment where participants could not
smoke?
“REALLY? Don’t you
wonder what the
Man with the
Yellow Hat and the
research say about
that?”
Our meta-analysis of 19 randomized controlled
trials evaluating tobacco treatment
interventions for individuals with substance
abuse problems found that smoking cessation
interventions were associated with a
25% increased likelihood of long-term
abstinence from alcohol and illicit drugs
(Prochaska, Delucchi, & Hall, 2004).
You read it right:
smoking cessation interventions were associated
with a 25% increased likelihood of
long-term abstinence from alcohol and
illicit drugs.
Summarizing Research Evidence:
http://www.ncbi.nlm.nih.gov/pubmed/2037828
National Center for Biotechnology Information
Prochaska, J. (2010) Drug and Alcohol
Dependence (110) 177-182
“In mental health and addiction treatment
settings, failure to treat tobacco dependence
has been rationalized by some as a clinical
approach to harm reduction. That is, tobacco
use is viewed as a less harmful alternative to
alcohol or illicit drug use and/or other selfharm behaviors. This paper examines the
impact of providers' failure to treat tobacco
use on patients' alcohol and illicit drug use
and associated high-risk behaviors.”
“The weight of the evidence in the literature
indicates:
(1) tobacco use is a leading cause of death in
patients with psychiatric illness or addictive
disorders;
(2) tobacco use is associated with worsened
substance abuse treatment outcomes, whereas
treatment of tobacco dependence supports
long-term sobriety;
(3) tobacco use is associated with increased (not
decreased) depressive symptoms and suicidal
risk behavior;
“The weight of the evidence cont’d:
(4) tobacco use adversely impacts psychiatric
treatment;
(5) tobacco use is a lethal and ineffective longterm coping strategy for managing stress,
and
(6) treatment of tobacco use does not harm
mental health recovery.
“Failure to treat tobacco dependence in mental
health and addiction treatment settings is not
consistent with a harm reduction model. In
contrast, emerging evidence indicates treatment
of tobacco dependence may even improve
addiction treatment and mental health
outcomes. Providers in mental health and
addiction treatment settings have an ethical duty
to intervene on patients' tobacco use and provide
available evidence-based treatments.”
“Providers in mental health and addiction
treatment settings have an ethical duty to
intervene on patients' tobacco use and provide
available evidence-based treatments.”
http://www.ncbi.nlm.nih.gov/pubmed/2037828
National Center for Biotechnology Information
Prochaska, J. (2010) Drug and Alcohol Dependence
(110) 177-182
Are there other ways a tobacco-free
environment might improve outcomes?
Over half of people who experience a substance
use disorder (SUD) also are living with a
mental illness (depression, anxiety, bipolar
disorder, PTSD, ADHD are the most common).
Journal of the American Medical Association
http://jama.jamanetwork.com/article.aspx?articleid=383975
Nicotine travels the same neuropathways
in the brain as a number of medications.
(Think high volume traffic.)Most notably:
• Psychiatric medications
• Cardiac mediations
Smoking
also stimulates liver enzymes that break down
the medications.
Lower medication doses often mean fewer side
effects.
To achieve a therapeutic effect, doctors
often prescribe at a higher dose.
• Increasing unpleasant side effects of
medication.
• Increasing the likelihood the patient will
discontinue taking medications.
Better outcomes for SUD clients occur
Occur when participants receive effective
treatment for the co-occurring disorders
at the same time.
Non-compliance with medications to
manage psychiatric symptoms may decrease
effectiveness of SUD treatment.
Drug Interactions With Tobacco Smoke
• http://www.ctri.wisc.edu/HC.Providers/menta
l.health/meds_aoda_mh.pdf
Are there other advantages for my site to
be tobacco-free?
People who smoke cost their employers
more money. A LOT of money.
How much?
Nearly $6,000 per year per employee.
•Higher health care costs
•“Presenteeism”—when people are at
work but not putting in full effort
•Cost of taking more sick days
•Cost of benefits and not having to pay
pensions to employees who die
prematurely
http://www.nbcnews.com/health/health-news/smoking-employees-cost-6-000year-more-study-finds-f6C10182631
Workplace tension?
Tobacco users taking more time for breaks?
IN the UK one study showed
smokers who step out of the
office for smoking breaks
work a whole week less
than their non-smoking
colleagues each year,
research shows
Read
more: http://www.dailymail.
co.uk/news/article2471058/Cigarette-breaksadd-week-workyear.html#ixzz3J5r4QNiC
Lower overhead and cleaner work
environment:
Construction and maintenance costs are
approximately seven percent higher in buildings
that allow smoking.
Businesses offering smoke-free environments enjoy
savings in cleaning and maintenance costs.
Department of Health and Human Services: Centers for Disease Control and
Prevention, "Clean Indoor Air Regulations Fact Sheet." National Center for
Chronic Disease Prevention and Health Promotion. April 11, 2001.
http://www.cdc.gov/tobacco/sgr/sgr_2000?
factshetts/factsheet_clean.htm
Smokers who want to quit – and research shows
that number to be as high as 75 percent – will
appreciate the smoke-free environment, too,
because it will assist them in their quit
attempt.
UW-CTRI, "How Smokers Quit," 2003 Wisconsin Tobacco Survey, Nov. 2004.
And you’ll experience less of this:
People who use tobacco don’t realize the heavy
smell of smoke that clings to their clothes and
hair. Especially immediately after a smoke
break.
Why did Phoenix Health Programs go
tobacco-free?
Why did Phoenix Health Programs go
tobacco-free?
It’s the most effective
treatment.
Why did Phoenix Health Programs go
tobacco-free?
It’s the most effective
treatment.
Best practices for SUD
treatment.
We used to
Watch people leave treatment. They were proud
of the strides they had made in quitting other
drugs.
And we knew most likely they would die of
tobacco-related disease.
We could no longer tolerate our
neglect as health professionals to
• Have one conversation
We could no longer tolerate our
neglect as health professionals to
• Have one conversation
• Share one piece of research
We could no longer tolerate our
neglect as health professionals to
• Have one conversation
• Share one piece of research
• Offer reason or strategy on quitting tobacco
With our clients.
Increments:
• Announced a year prior to implementation of policy. Oct.
2008.
• Moved to NEW building—Dec. 2009
• Educated staff regarding research to offer more effective
treatment for those we serve.
• Agency offered free Freedom From Smoking Classes for
staff.
• Had “agency quit day”—celebration—snacks an bottles of
water.
• Those receiving treatment for tobacco had “support
buddies” who offered small notes and gifts of
encouragement.
Other considerations for staff:
•
•
•
•
•
•
Signage—on grounds, in building.
Written policies.
Education of staff RE: policies and consequences
Monitoring and compliance
Butt pick-ups
We don’t come back from lunch smelling like
alcohol—we also don’t come back smelling like
tobacco smoke.
Staff achievements:
• Employee smoking rate before Tobacco free
policy: about 65%
• Employee smoking rate after tobacco free
policy: about 16%
Note: it dropped lower then the rate of tobacco
use in MO which is 25%--which had been the
goal.
What about clients?
• Begins at FIRST CONTACT: Informed during initial
screening we are tobacco-free. Screener form
requires staff doing the screenings note they have
discussed this policy.
• Informed “it’s the most effective treatment.”
• Clearly listed on “What Should I Bring to
Treatment?”—don’t bring tobacco, do bring
nicotine replacement products.
• Tobacco users are now required to bring NRP or
$30 money order so we can purchase.
Clients (continued):
• Using tobacco in residential may be grounds for
dismissal (sometime behavioral contract and
work with counselor).
• Freedom From Smoking® classes offered as part
of comprehensive treatment (not required).
• Tobacco “quiz” during education group to clarify
“it’s the most effective treatment.”
• Can’t make you stop—only “interrupt” and be
more intentional about your health.
Clients (continued):
• Mayo clinic tobacco treatment specialist to help
achieve proper dosage with NRP.
• Help see as “therapeutic environment” –much like low
salt diet if you were in the hospital for hypertension.
“You’ll decide what you want your recovery to look like
when you get out.
• Help client figure how much spent annually on
tobacco.
• During Screener often client –asked “on 1-10 scale,
how interested are you in a conversation on how we
help people quit tobacco?” If score at 5+ on interest,
are referred to tobacco treatment specialist.
Challenges:
• Policies with other entities.
• Have to clarify—no e-cigarettes either.
• Some staff have resumed tobacco use. FFS
classes still available.
• Myths persist—clients think “you make more
money” or “My sponsor says it’s too stressful.”
• Outpatient clients
Solid progress:
• We no longer create tobacco users.
• Staff is aware of tobacco- free as effective
treatment.
• Introduce clients, families and our community to
tobacco free as effective treatment.
• Staff address smoking on property—treat as one
might a no parking zone. “Oh, maybe you didn’t
see the sign. Thank you so much for your help.”
Steps you can take:
• Read the research.
• Open the conversation with administrators. “I’m
wondering what steps we can take . . .”
• Share the research.
• Resource: “Recommendations for Policies and
Procedures in Substance Use and Mental Health
Treatment Settings.” Wisconsin
http://www.ctri.wisc.edu/tobaccofree.pdf
More steps:
• Find the “champion”—the leader in your
agency who will keep the energy behind this.
• Cite savings to workplace.
• Advocate for all clients and staff to have better
chance for healthier lives.
• Request non-tobacco users have lower
insurance rates.
Embrace the struggle:
“Substance use issues are so expensive,
disruptive, so compromising of the quality of
life for millions—why wouldn’t we want
people to have the best possible outcomes as
a result of their trying to change their lives?”
-Heather Harlan
Barriers and resistance:
• Traditional thinking. “I didn’t do it that way.”
• 12 step groups where there are high numbers
of smokers
• Co-workers
• Administrators who don’t see it as “a priority”
• Clients
Point to recent advances and future:
• Boone Hospital Center in Columbia—no
longer will hire people who smoke.
• University of MO smoke free campus
• More health care agencies are following this
lead.
Mission
Possible:
You can go
from this . . .
Phoenix Health Programs, Inc
• Know us
• “Like us”
• Follow us.
So you can become a member of the
informed community.
Presenter would like to acknowledge:
• Deborah Beste, Executive Director, Phoenix Health
Programs—our visionary director
• Greg Carbins, Mayo Clinic trained and certified Tobacco
treatment specialist at Phoenix Health Programs—our
boots on the ground champion
• Dr. Joe Parks, Chief Medical Officer for the MO Dept of
Mental Health—who inspired us to believe people with
mental illnesses deserve and want opportunities to
strengthen wellness.
• Julie Sears, Prevention Specialist and former co-worker
who was our original champion, trainer and cheer leader.
Thank you!
Questions? Discussion?
Presented by Heather Harlan, CRPS (Certified Reciprocal Prevention Specialist)
573-875-8880 x 2142
A copy of this presentation available on request:
[email protected]
For individuals. For families. For over 40 years.
Funding for this project was provided in part by the Missouri
Foundation for Health. The Missouri Foundation for Health
is a philanthropic organization whose vision is to improve
the health of the people in the communities it serves.