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Module 1 - The Foundation:
Integrating Tobacco Use Interventions
into Chemical Dependence Services
Welcome
Add Trainer Names
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This training was developed by the Professional
Development Program, under a contract with the
NYS Department of Health, Tobacco Control
Program.
PDP developed five classroom-based curricula
and seven online modules, which are available at
www.tobaccorecovery.org
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Housekeeping
 Hours of Training
 Breaks and Restrooms
 Tobacco Use Policy
 Cell Phones
 Active Participation
 Complete Training Evaluation
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Introductions
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Training Modules
Module 1 - The Foundation
Module 2 - Assessment, Diagnosis, Pharmacotherapy
Module 3 - Behavioral Interventions
Module 4 - Treatment Planning
Module 5 - Co-occurring Disorders
E-Learning - All Modules (www.tobaccorecovery.org)
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PM 8
Module 1 Agenda
 Introductions
 Attitudes and Beliefs Activity
 A Brief History
 Rationale
 Tobacco Dependence
 NYS OASAS Regulation Part 856
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PM 9
Module 1 Objectives
Please refer to the list of objectives in your manual.
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PM 9
Unit 1
Setting the Stage
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PM 11
Attitudes and Beliefs
The purpose of this activity is to help you explore
your attitudes and beliefs about:
 Tobacco use
 Integrating tobacco interventions into chemical
dependence services
 Tobacco use, dependence, and recovery
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PM 12
Attitudes and Beliefs, cont’d
Debrief
and
Process
11 PM 12
Timeline
• 1798 – 1970s: Recognition of Tobacco
Dependence - Lost and Found
• 1980s - 1990s: Emerging Awareness
• 2003 - 2008: A New Century
12 PM 13
RECOGNITION OF
TOBACCO DEPENDENCE
Lost and Found
1798
13 PM 13
1870s
late 1800s,
early 1900s
1930s
1960s-1970s
1798: Benjamin Rush, a physician and
signer of the Declaration of
Independence, identifies tobacco use as a
harmful substance and observes that use
supports excess alcohol consumption.
RECOGNITION OF TOBACCO
DEPENDENCE
1798
14 PM 13
1870s
late 1800s,
early 1900s
1930s
1960s-1970s
1870s: Tobacco is identified as
both a harmful addictive substance
and as contributing factor in
relapse from alcoholism and drug
dependence.
RECOGNITION OF TOBACCO
DEPENDENCE
1798
15 PM 13
1870s
late 1800s,
early 1900s
1930s
1960s-1970s
Late 1800s and early 1900s: Tobacco
dependence is routinely treated along
with alcoholism and other drug
dependence in inebriate clinics and
asylums.
RECOGNITION OF TOBACCO
DEPENDENCE
1798
16 PM 13
1870s
late 1800s,
early 1900s
1930s
1960s-1970s
1930s - Oxford Group principles used
to help support early recovery efforts;
Oxford Group frowns on tobacco use.
1935: Beginning of Alcoholics
Anonymous. Alcoholism counseling
begins to evolve. Tobacco use becomes
embedded in recovery practices and the
recognition as a serious addiction and
recovery issue is lost for many years.
RECOGNITION OF TOBACCO
DEPENDENCE
1798
17 PM 13
1870s
late 1800s,
early 1900s
1930s
1960s-1970s
1964: Surgeon General Report
on Smoking and Health
indentifies the adverse health
effects of tobacco use.
1960s: Alcoholism counseling continues to
evolve. 1970s: Many former drug users
become drug abuse counselors. Most
counselors in both groups use tobacco.
RECOGNITION OF TOBACCO
DEPENDENCE
1870s
18 PM 13
late 1800s,
early 1900s
1930s
1960-1970s
EMERGING AWARENESS
1985
19 PM 14
1992
1996
1985: Geraldine Delaney,
founder of Little Hill-Alina
Lodge in New Jersey, makes
this the first tobacco-free
chemical dependence treatment
program.
EMERGING AWARENESS
1985
20 PM 14
1992
1996
1992: John Slade, M.D. begins the
Addressing Tobacco in the Treatment
of Other Addictions Project at the
University of Medicine and Dentistry
of New Jersey (UMDNJ)
EMERGING AWARENESS
1985
21 PM 14
1992
1996
1996: Van Dyke and Norris
Addiction Treatment Centers
(ATC) become the first tobaccofree chemical dependence inpatient
treatment programs in New York
State. Stutzman ATC follows in
1997.
EMERGING AWARENESS
1985
22 PM 14
1992
1996 -1997
A NEW CENTURY
2003
23 PM 15
2004
2005
2006
2007
2008
2009
2003: Passage of NYS Clean Indoor Air Act, which exempts
substance abuse and mental health treatment programs.
2003: American Cancer Society and ASAP of NYS create a
mission statement to promote tobacco-free chemical
dependence programs. OASAS task force convenes to discuss
tobacco regulations and resources.
2003: NYS Partnership for the Treatment
and Prevention of Tobacco Dependence
convenes.
A NEW CENTURY
2003
24 PM 15
2004
2005
2006
2007
2008
2009
2004: Founding of Tobacco Recovery
Coalition of the Capital District, Albany, NY.
2004: OASAS Commissioner William Gorman
Policy Statement that stated:
Prevention and treatment providers should
address all addictions including nicotine.
A NEW CENTURY
2003
25 PM 15
2004
2005
2006
2007
2008
2009
2005: All 13 OASAS-operated Addiction Treatment
Centers (ATCs) in transition to be tobacco-free programs.
August 2005: OASAS Medical Director letter to all
OASAS certified providers: “Addiction providers are best
positioned to help patients become tobacco free to increase
the quality of their lives in recovery.”
2005: Some NYS chemical
dependence providers begin
implementing similar policies,
becoming tobacco-free agencies
A NEW CENTURY
2003
26 PM 16
2004
2005
2006
2007
2008
2009
May 2006: ASAP opens
NYS Tobacco Dependence
Resource Center.
November 2006: ASAP launches
www.tobaccodependence.org.
December 2006: OASAS releases Local Services
Bulletin No. 2006 – 10: Tobacco Dependence
Practice Guidelines.
A NEW CENTURY
2003
27 PM 16
2004
2005
2006
2007
2008
2009
July 2007: OASAS Commissioner, Karen Carpenter-Palumbo Announcement of Regulation Part 856 Tobacco-Free Services, to be
effective by July 24, 2008.
ASAP Questions and Answers about Tobacco-Free Chemical Dependence
Services teleconference series begins.
August 2007: NY Tobacco
Control Program issues RFP
to provide statewide training
and technical assistance to
integrate tobacco
interventions into services.
September 2007: TCP starts providing
$4M in Over-the-Counter Nicotine
Replacement Therapy (OTC NRT) products
to Patients and Staff of OASAS programs.
A NEW CENTURY
2003
28 PM 16
2004
2005
2006
2007
2008
2009
January 2008: TCP awards training and technical
assistance contract to Professional Development
Program, University at Albany.
March - July 2008: PDP begins training and technical
assistance, launches www.tobaccorecovery.org website,
selects Regional Training Centers, designs Modules 1 and
2, and begins statewide training.
July 24, 2008: OASAS Regulation Part 856
Tobacco-Free Services goes into effect.
October - December 2008: PDP launches
Module 3 and Online Modules 1 and 2.
A NEW CENTURY
2003
29 PM 16
2004
2005
2006
2007
2008
2009
January – December 2009: PDP launches Modules 4 – 5, Online
Modules 3 – 7, and completes statewide classroom training.
2009: Family Smoking Prevention and Tobacco Control Act
enacted. The FDA is finally given the legal authority to regulate
tobacco, nicotine levels, and tobacco additives, excluding menthol.
States of Washington and Texas: decide to implement tobaccofree addiction treatment services.
A NEW CENTURY
2003
30 PM 16
2004
2005
2006
2007
2008
2009
Rationale
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PM 17
Mission and Purpose
 Treating tobacco dependence is consistent
with the mission and purpose of chemical
dependence services
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PM 17
Mission Statement Example
“We provide quality, cost-effective care to those
suffering from alcoholism and chemical
dependency and to the many whose lives
are affected by the diseases of addiction.”
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PM 17
Mission Statement Example 2
“Our mission is to provide a quality continuum
of comprehensive treatment and related
services, in a caring atmosphere and at a
reasonable price, for all people
experiencing problems with alcohol or
other drug use.”
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PM 17
Skills and Knowledge
 Treating tobacco dependence requires the
same skills and knowledge that addiction
professionals already have to treat chemical
dependence
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PM 17
Tobacco’s Relationship to
Alcohol and Other Drugs
Prevalence of Tobacco Use (National Data)
 General Population
19.8%
 Addiction Treatment
60 – 95%
 Serious Mental Illness
75 – 80%
 HIV and AIDS
50 – 70%
36 PM 18
Tobacco Use 7 Days Prior
To Admission in 2006
Level of Care
% Using
% Males
% Females
Intensive Residential
76 %
74 %
82%
Community Residential
73%
71%
80%
Supportive Living
81%
79%
84%
Inpatient Rehabilitation
80%
79%
82%
Outpatient Clinic
63%
63%
65%
Outpatient Rehab
77%
76%
79%
Methadone Clinic
83%
82%
84%
37 PM 18 -19
Data: 2006, OASAS Certified Programs
38 PM 20
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PM 20
Tobacco Industry Practices
 Knowingly sells a product that when used as intended
causes serious disease and death
 Targets youth and denies doing so
 Lots of money and no morals
 Continues to lobby against further tobacco regulation
 Uses massive advertising campaigns, plus insidious
and deceptive marketing
41 PM 20
Toll of Tobacco Use
General Population - Annually
Deaths
over 438,000
Health care and productivity cost
$194.3 billion
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PM 21
Toll of Tobacco Use
Tobacco-Related Deaths
are greater than
Alcohol or Drug-Related Deaths
among people treated for chemical dependence
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PM 21
Toll of Tobacco Use
 Bill W.
 Dr. Bob
 Marty Mann
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PM 21
Toll of Tobacco Use
 For every person who dies from their tobacco
use, there are twenty people living with serious
health problems caused by their tobacco use.
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PM 22
Toll of Tobacco Use
Tobacco-Related Health
Consequences:
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PM 22 -23

Commonly known

Less commonly known
Integrated Tobacco
Dependence Treatment
 Efficacy
 Improved Outcomes
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PM 24- 25
Unit Two
Tobacco Dependence
Tobacco Dependence
Why do people use tobacco?
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PM 28
Tobacco Dependence (cont’d)
Nicotine Dependence
vs.
Tobacco Dependence
DSM III / III-R used the term “tobacco dependence.”
Why did this change to “nicotine dependence” in the
DSM-IV / DSM IV-TR?
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PM 28
Nicotine dependence compared to
cocaine and amphetamine dependence
amphetamine
DA
cocaine
ACh
nicotine
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PM 29
Theories for Tobacco Use Prevalance
 Shared Characteristics
 Reinforcing Effects
 Shared Brain Pathways
 Modulating Effects
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PM 30
DSM-IV-TR Criteria
 Nicotine dependence criteria is not unique
or different
 DSM-IV-TR substance dependence criteria
is used for diagnosing nicotine
dependence (a.k.a. tobacco dependence)
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PM 31
DSM-IV-TR Criteria, cont’d
 Nicotine Withdrawal
 Daily use for several weeks
 Cessation is followed within 24 hours by four or
more physical or behavioral signs.
 Symptoms causes significant distress and
impairment and are not due to medical
condition or other mental disorder
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PM 32
Tobacco Dependence Treatment
 Management of withdrawal is critical to
successful recovery
 Strong evidence of medication effectiveness
 Medication effective for many populations
 Insufficient evidence of effectiveness only
with a few populations
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PM 33 - 34
Tobacco Dependence Treatment (cont’d)
 First-Line medications
 Nicotine Replacement Therapy (NRT)
 Non-nicotine medications
 Combination of medications is best
 Other medication levels may be affected
after stopping tobacco use
 Few medical contraindications
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PM 35 - 36
Tobacco Dependence Treatment
(cont’d)
 Supportive Counseling
The combination of counseling and medication is
more effective than either alone
Motivational Interviewing, Cognitive Behavioral
Therapy, Skills Training, and Relapse
Prevention Therapy are all effective
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PM 37
Summary - Nicotine Replacement
Therapy
 Nicotine medications have wide margin of safety
 Dose should be at least equivalent to tobacco use
 Combining tobacco medications is more effective
 Patients with other chemical dependencies may
require higher dosage and longer term NRT
 Under-dosing may not manage withdrawal
symptoms and often results in relapse
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PM 37
Comparison of Nicotine Delivery
Diagram shows rise in nicotine levels in plasma after smoking a cigarette and after using
different nicotine replacement therapy products (Adapted from Royal College of Physicians
Website, per MAH Russell,1987 Nicotine intake and its regulation by smokers)
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PM 38
The Cigarette:
A Perfect Drug Delivery Device
 Cigarettes - highly engineered nicotine
delivery device
 1 cigarette can peak the nicotine blood level 5-
7x higher than the effect of a 21mg
nicotine patch
 300 hits per 1 ½ pack of cigarettes
 Exact Titration: frequency of use, intensity,
and ability to fine tune delivery of nicotine
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PM 39
The Cigarette:
A Perfect Drug Delivery Device (cont’d)

Allows exact dosing by user

Severely addicted smokers and those with
limited income often re-light

Menthol cigarettes – allows deeper inhalation
using less cigarettes to achieve higher nicotine
levels
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PM 39
How Tobacco Dependence Differs
from AOD Dependence
 Tobacco use does not cause intoxication
 Tobacco use generally does not cause adverse
behavioral outcomes
 Tobacco use does not produce intense euphoria
 Tobacco use may minor perceived improvements in
cognitive functioning and mood
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PM 40
How Tobacco Dependence is Similar
to AOD Dependence
 Affects release of dopamine and other
neurotransmitters in the brain
 Continued use despite serious harmful effects
 Withdrawal syndrome
 Rapid rates of relapse after attempts to stop
 Nicotine self-administration in animal studies
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PM 40
Reframing Language
Public Health
Terminology
smoking
smoker
quit date
cessation
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PM 41
Recovery Terminology
Challenges in Treating Tobacco
Dependence
 Nicotine has strong negative and positive
reinforcement
 Nicotine has some perceived beneficial effects
 Smoking tobacco provides most intense reward
effects
 Nicotine is not intoxicating
 Nicotine withdrawal
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PM 42 - 43
Unit Three
OASAS Regulation
Part 856
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PM 45
Part 856 Tobacco-Free Services
 What is the OASAS regulation?
 What is expected of:
 Patients
 Staff and Volunteers
 Program Administrators
67 PM 45
Part 856 Tobacco-Free Services (cont’d)
 OASAS Regulation effective July 24, 2008
 Requires all OASAS certified and funded
programs to “determine and establish written
policies, procedures and methods governing the
provision of a tobacco-free environment.”
- Section 856.5 (a)
68 PM 46 -47
Tobacco-Free Environment
 Tobacco-Free: No use of tobacco products in a
program’s facilities, grounds or vehicles owned
by or under the control of the program
 Facility: The space used by the program’s
patients, staff, volunteers, and visitors
 Limited to space “under the direct control” of the
program
- Section 856.4
69 PM 48
Minimum Policy Requirements
 Define the facilities, vehicles and grounds.
 Prohibit patients and visitors from bringing
tobacco products and paraphernalia to the
program.
 Notify patients, staff, volunteers and visitors of the
policy in writing.
 Prohibit staff from using tobacco products while at
work, during work hours.
70 PM 49
Minimum Policy Requirements (cont’d)
 Establish tobacco-free policy for staff while on the
work site.
 Establish treatment modalities for patients who
use tobacco.
 Describe tobacco training available to all staff.
 Describe tobacco prevention and education
programs available to patients, staff,
volunteers, and others.
71 PM 49
Minimum Policy Requirements (cont’d)
 Establish procedures to address patient tobacco
relapse.
 “… every effort shall be made to provide
appropriate treatment services…”
 Establish procedures to address staff tobacco
 “relapse consistent with the employment
procedure…”
- Section 856.5
72 PM 49
Implications of the Regulation
 Patients, staff, volunteers, and visitors may not use
tobacco on program’s buildings, grounds, and
vehicles.
 Patients, family members, and other visitors may
not bring tobacco or paraphernalia to the
program.
 Staff may not use tobacco products at work,
during work hours.
73 PM 50
Program Administrator
Responsibilities
 Write a tobacco-free environment policy.
 Post notices and provide policy to all patients,
staff, volunteers, and visitors.
 Identify tobacco prevention and education
programs available to patients, staff,
volunteers, and visitors.
 Establish treatment modalities for patients who
use tobacco.
74 PM 50
Program Administrator
Responsibilities
 Identify tobacco use and dependence training
available for staff and volunteers.
 Establish procedures for patient and staff policy
violations.
 Manage organization’s change process.
75 PM 50
Regulation 856 – True or False?
Patients, family members, or other
visitors may not bring tobacco or
tobacco paraphernalia to the
program or service.
76 PM 51
Regulation 856 – True or False?
OASAS-funded Permanent Supportive
Housing and Vocational Rehabilitation
programs are exempt from the regulation.
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PM 51
Regulation 856 – True or False?
Staff may use tobacco during work hours,
while on break, and off premises.
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PM 51
Regulation 856 – True or False?
For residential treatment programs,
patients who relapse on tobacco must be
administratively discharged.
79
PM 51
Regulation 856 – True or False?
For outpatient treatment programs, all
patients must stop using tobacco for
the duration of their treatment.
80 PM 51
Resources
The Tobacco Recovery Resource Exchange
http://www.tobaccorecovery.org
E-Learning and Online Resources
OASAS http://www.oasas.state.ny.us/tobacco/index.cfm
Email: [email protected]
81 PM 53-54
Workshop Evaluation Form
and
Post Test
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