Tobacco-free on Valentine`s Day: Why recovery lovers hate smoking

For many, Feb. 14 means giving and receiving gifts, going to dinner, and spending time with a significant other to express love in a relationship.  For those at the Aurora, Colo. Addiction treatment center CeDAR (Center for Dependency, Addiction and Rehabilitation), this Feb. 14 will mean giving back to themselves in a healthy way, according to Executive Director Steve Millette, MS, LAC. 

Valentine’s Day will be the “quit date” at CeDAR– the day that all patients and staff are no longer allowed to use tobacco products on campus.  Laura Martin, MD, ABAM, Medical Director at the Center for Behavioral Health and Wellness within the Department of Psychiatry at the University of Colorado School of Medicine (CeDAR is part of the University of Colorado Hospital affiliated with the School of Medicine), had the idea to implement the policy on Feb. 14.  She says the timing has to do with the imagery of the heart, “taking care of our heart and taking care of ourselves.”  The relationship with ourselves, she says, is a very important relationship that “frequently we give up when we’re not in recovery and leading well lives.”

Millette says the idea was born last summer during a staff meeting.  While discussing patient care and various other policies, the group reviewed data from the nicotine cessation efforts that were currently in place at CeDAR.  “The data was disappointing to say the least,” recalls Millette.

Visible was a trend of people coming into treatment as non-smokers and leaving as smokers.  Additionally, Millette says not enough people were being successful in their nicotine cessation efforts.  The next question asked by the group: “Are these nicotine cessation efforts ever going to be successful if we continue to allow patients to smoke on the premises?”

Millette comments, “It’s akin to patients having access to alcohol while they’re here—would we allow that?”

As a key resource in the planning and implementation of a smoke-free policy, Martin and her team were instrumental in putting together a toolkit, says Millette.  For the last six months, Millette says they have been actively working on this process and trying to anticipate all of the potential concerns people might have about it.

Preparation

Since the tobacco-free policy applies to CeDAR staff as well, Martin, one of CeDAR’s attending psychiatrists, says multiple approaches were taken. One approach was to make staff members who are currently smokers aware of resources for treatment.  This includes providing educational sessions related to treatment of tobacco dependence, constantly working to identify their readiness for the transition, addressing any concerns they may have, and providing additional support that they need, she says.

With the patients, the organization held multiple focus groups “to elicit their hopes, dreams, fears and what practices would be most helpful for them in this transition,” Martin explains.  CeDAR has also added a Nicotine Anonymous (NA) group to its campus, and has been specifically working with smokers and smokeless tobacco users throughout the past several weeks to assist in their “game plan” of how they will approach Feb. 14.  Martin says that some individuals decided they would try to quit sooner rather than later, while others decided to wait until the policy goes into effect.

Focus groups were conducted for the patients to discuss their thoughts on the new policy.  Martin says some patients shared concerns about how hard the transition would be, while others said that the policy was unfair.  A majority of the individuals, however, were excited by the prospect that quitting tobacco while in treatment would increase their chances for recovery, says Martin.

“During the focus groups, I was struck by the fact that 10 to 20% of the smokers in each group either started smoking while in rehabilitation and/or increased the amount they were smoking or relapsed while they were in rehabilitation treatment,” Martin recalls.

Martin says CeDAR held these focus groups early enough so the majority of the participating individuals would be discharging prior to the transition.

Additionally, there were focus groups conducted without patients.  The first several were with staff and one included staff and alumni because in early announcements about the policy, CeDAR received feedback from alumni that was both positive and negative, according to Millette. 

He says many of the patient alumni had similar comments to those of the current patients:  “It’s not fair,” “It’s making treatment harder,” “You’re putting people’s recovery at risk because quitting tobacco at the same time as other drugs just makes recovery chances harder,” etc.

Therefore, he explains that one of the main purposes of these focus groups was to dispel the myths that people had about this process.  It was important to the administration, he says, to share with the concerned patients and alumni some of the telling research findings that led the way to this policy decision.

“The research doesn’t support the common perceptions that it makes recovery harder, treatment less effective, or that it’s going to have an adverse effect on people wanting to come into treatment. So dispelling those myths was really important and once we did that, we saw a pretty good turnaround in people’s attitudes about it,” Millette says. 

Staff concerns

Because employees may not feel comfortable speaking in front of their superiors and/or peers about their concerns, CeDAR sent around an anonymous survey for staff, alumni and volunteers.  The survey had questions about perceptions regarding tobacco, the treatment of nicotine dependence, their feelings on the importance of the policy, and their readiness and confidence in this. Martin reports that there were “high levels of confidence in the ability to do this and the importance.”

Historically what Martin’s program has encountered in working with other organizations that are going tobacco-free, especially with psychiatric hospitals, is that in the end it was primarily the staff who had the most difficulty with the transition. However, that has not been the case at CeDAR and she says she’s surprised she hasn’t heard more concerns.

Millette adds, “We knew in the beginning that we would have to take a concurrent approach, knowing that the staff issues would be primary when it comes to whether we’re successful or not.

“The patients – once we get through the cohort of people who are sort of in the middle of the process –really won’t know any different.  When they’re coming in a month or two after the policy takes effect, it’ll be treatment as usual for them,” he continues.

Changes in census

For the past several weeks, Millette says the admissions staff has made all new patients and families aware of the upcoming policy.  “In some regards we wanted to make sure all the patients who were going to be here on Feb. 14 had advanced notice, and so they made a more conscious decision about it,” he says.

Martin says the information about the policy is not only coming from admissions, but is also on the CeDAR website. The center has had two individuals come into treatment who thought the campus was already completely tobacco-free.  She says they were ready to stop when they came in and were disappointed the program hadn’t yet begun, but continued their quit attempts anyway when they got into treatment.

A common fear when a treatment center goes tobacco-free is that the census will drop.  As Marketing Director, Rollie Fisher was worried about this as well but says he has seen the exact opposite – a record number of admissions over the past two weeks.  And, as of today, Fisher says there has not been one person who has said he/she will not come to treatment at CeDAR because of the policy.

Goodbye and hello

On the evening of Feb. 13, Martin says there will be special programming to assist individuals in this transition. Here, all individuals who are still smoking at that time will smoke their final cigarette.  After that, CeDAR administration will collect all the tobacco products and have a “letting go ceremony.” 

“We’re going to have an opportunity for everybody to share their stories as well as their goodbyes, to talk about the loss but at the same time to recognize the gains,” Martin explains.

Also that evening, the special smoking areas and ashtrays will be removed from the campus.   On the day the policy goes into effect, during one of the break times when the individuals are normally smoking, they will participate in some sort of activity to fill those spaces in a positive way.  Depending on the weather, Martin says the activity may be to plant flowers or create markers that convey the hope and recovery principle CeDAR projects.

New services available

Services that now will be available will include educational sessions, nicotine cessation groups, Nicotine Anonymous groups, 12-Step meetings, and a peer-to-peer program.  The latter, which the Behavioral Health and Wellness staff will help put online, will serve to address people who may not be able to get to NA meetings, to help extended care patients participate, and to garner some support from volunteers and alumni who attend various events. 

As far as the clinical side, Millette says CeDAR will include tobacco issues in its assessments, and if it’s seen as  a problem area it will be addressed in the treatment plan.  Also, there will be a range of medication assistance—whether it’s nicotine replacement (patches, gum, lozenges) or other medications that are known to be effective. He says the hospital pharmacy serving CeDAR will now include the medication Chantix as a standard formulary drug for CeDAR’s patients. 

Another layer to this process, Millette expresses, is sharing the information with other treatment providers.  “While we’re primarily concerned with improving our patients’ care and their outcomes, we’re also committed to documenting our experience because we know that unless organizations are forced into it, oftentimes they don’t go down this road,” he says.  “We want to make that information available to the field so that more treatment programs around the country are willing to do it proactively as opposed to reactively to some mandate that the state is putting on them.”