“To Dream The Impossible Dream:Your Site CAN Go Smoke Free”

Heather C. Harlan, CRPSACT Missouri Prevention Conference

Lodge of the Four SeasonsTuesday, November 18, 2014

Do you everfeel 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?

Counselor’s Offices

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 cancerCervical 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.Noun3.a pandemic disease.

Endemic [en-dem-ik]adjective, Also, endemical1.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.

Noun3.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-science-addiction/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 InformationProchaska, 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 self-harm 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 long-term 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 InformationProchaska, 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 Associationhttp://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

Smokingalso 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/mental.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-6-000-year-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/article-2471058/Cigarette-breaks-add-week-work-year.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 toWatch 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.

• 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.

We could no longer tolerate our neglect as health professionals to

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?

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.

Presented by Heather Harlan, CRPS (Certified Reciprocal Prevention Specialist)573-875-8880 x 2142A copy of this presentation available on request:hhharlan@phoenixhealthprograms.com