Toolkit Offers Modern Approach to Reducing Cigarette Smoking in SUD Populations

The percentage of Americans aged 18 and over who smoke cigarettes is 14%. Two recent publications from the Recovery Research Institute indicate that the rate of tobacco use among persons receiving recovery support services is dramatically higher. It is noteworthy that these studies are of substance use disorder recovery populations as opposed to populations engaged in treatment or pre-treatment.

The first study¹ surveyed 275 new attendees at recovery community centers in New England and reported a current tobacco use rate of 60.7% (ever used 74.5%). The second study² of 336 recovery community center participants in the Northeast United States reported a current tobacco use rate of 42.6% (ever used 63.7%).

The mortality and morbidity associated with smoking is well-known. According to the Centers for Disease Control and Prevention, smoking increases the risk of dying from bronchitis and emphysema by 17 times for men and 12 times for women; from cancer of the trachea, lung and bronchus by more than 23 times for men and 12 times for women. Smoking also increases the risk of dying from coronary heart disease among middle-aged men by almost four times and middle-aged women also by four times.

Smoking and concurrent alcohol and drug use has a multiplicative effect. A 24-year study of more than 400 narcotic treatment patients who smoked found a death rate four times that of nonsmokers.³

The health community’s acceptance of these high rates of smoking among recovery populations amounts to a deadly case of benign neglect. As reported previously:

Unaddressed addiction to cigarette smoking among treatment and recovery populations is responsible for disease and premature death among a substantial number of Americans who achieve long term recovery from their substance use disorder.⁴

It is noteworthy that the co-founders of Alcoholics Anonymous both died of smoking-related illnesses.

The Smoking and Recovery Toolkit was created to directly address this public health failing. While the tobacco control and smoking cessation fields present an array of programs, websites and strategies, none are specifically designed to speak to the unique relationship between alcohol/drug addiction and smoking.

>> DOWNLOAD THE SMOKING AND RECOVERY TOOLKIT

Addiction treatment has undergone a sea change in the past quarter century. Abandoned is the belief that a person must “hit bottom” to commence recovery. Stages of change theory has replaced folklore. No longer do we in the addiction treatment community require a commitment to abstinence as a prerequisite to care. Gone are the days when a recurrence often led to a program discharge. Now we endeavor to meet the client where they are and to engage in a use and risk reduction plan tailored to their needs. These lessons inform the contents of the Toolkit.

Because the very high rates of smoking continue in the recovery population, it is reasonable to conclude that existing abstinence-based “cessation” approaches are not meeting the needs of this population.

With alcohol and drug addiction we no longer blame the client with conclusions such as “he/she is not ready yet.” Instead, we have learned through motivational and stages of change theory that incremental approaches work better for many. So, the question to the smoker is not “Are you ready to quit?” but rather “Would you like to do something about your smoking?” The first statement requires a binary yes/no. The second is likely to surface some ambivalence, or discrepancy in motivational therapy language, which opens the door for a conversation about reducing risk.

Inspiration for the Toolkit came from focus groups conducted in 2019 at several treatment and recovery programs in Northern California. One was held at a medication-assisted outpatient treatment program in an agricultural region that serves a largely Latino population. Two focus groups were held at a recovery community center (RCC) in an urban setting that serves African American and Latino members. Of the 25 participants from the RCC, 13 were concurrently receiving outpatient and residential treatment services. In total, of the 36 focus group participants, 39% were African American, 33% were Latino, 14% identified as Caucasian and 8% were Asian Pacific Island. Six percent declined to identify their race.

Most of the participants reported that they had been struggling with their addiction to cigarettes for years both before, during and after seeking treatment/recovery from alcohol or other drugs. In many cases the use of cigarettes was/is inextricably interwoven with their other addictions, as well as their treatment and recovery episodes. Many participants spoke of initiating cigarette smoking during childhood, in one case as early as age 8. The overwhelming majority described families in which smoking, and alcohol or drug use was commonplace. Almost all participants described numerous attempts to reduce or quit cigarette use, almost always unsuccessful. Many expressed surprise and disappointment that they still smoke cigarettes, though well into their recovery from alcohol/drug abuse.

The Toolkit is divided into organizational tools designed to help treatment programs and recovery centers improve their competence to address cigarette smoking in activities and facilities. Included in this section are a list of tobacco harm reduction best practices and policies and a slide show for training staff.

A second section focuses on individual tools to assist individuals to assess and reduce their smoking risk. Here users will find recovery-friendly information to help evaluate current use and tools to plan and implement smoking behavior change.

Innovation rarely occurs as something unique and fully formed. Often it is the result of an iterative process that recombines existing knowledge into new forms. Such is the case here. We have ample evidence of a deadly problem, i.e., smoking among SUD populations. We have strategies to address the problem, i.e., tobacco harm reduction approaches. What is lagging is a full-throated commitment to implement and scale up these remedies.

John de Miranda is an independent consultant who has worked in the alcohol and drug problems field for most of the 47 years he has been in recovery. He is recipient of 2019 and 2020 Tobacco Harm Reduction Scholarships from Knowledge Action Change. He can be reached at 650-218-6181 or solanda@sbcglobal.net.

References

1 Kelly, J.F. et al. Recovery community centers: Characteristics of new attendees and longitudinal investigation of the predictors and effects of participation, Journal of Substance Abuse Treatment, 124, (2021) 108287.

2 Kelly, J. F. et al. One-Stop Shopping for Recovery: An Investigation of Participant Characteristics and Benefits Derived from U.S. Recovery Community Centers, Alcoholism: Clinical and Experimental Research, Vol 44, No 3, 2020: pp711-721.

3 Hser, Y. I., McCarthy, W. J., & Anglin, M. D. (1994). Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Preventive Medicine, 23, 61−69.

4 de Miranda, J. Harm Reduction Approach Should Extend to Patient Smoking, Psychiatry & Behavioral Health Network, 12/31/19.