Many addiction specialists understand and accept the important role nicotine dependence plays in the treatment of their patients’ addiction to alcohol and other drugs. Each year, many more programs institute nicotine-dependence treatment alongside treatment for other addictions within their facilities. Some programs across the country now understand the nature of the beast so well that they even require their staffs to be tobacco-free.

"Roughly 10 to 20 percent of programs now address tobacco alongside other chemical dependency in their treatment programs," said Catherine McDonald, M.D., M.P.H.

McDonald, an addiction treatment specialist and medical consultant at Thunder Road Chemical Dependency Recovery Hospital and Group Home in Oakland, Calif., is a strong advocate of doing so and frequently lectures on her quest to make Thunder Road a tobacco-free facility.

Thunder Road began its efforts to require that both staff and patients be "free from evidence of tobacco use" in June 1994. By August 1998 the facility was still struggling to implement the watered-down requirement that staff "should not be identifiable as a tobacco user while at work." In August 1999 that policy went into effect.

"The transition," McDonald told Psychiatric News, "was long and difficult. But what we found was that you had to go slow, to give your staff time to assimilate the logic and reasons for the change."

The reasons to address nicotine addiction are indeed compelling. Nicotine, noted McDonald, is as addictive as heroin. And 90 percent of substance abusers smoke tobacco. In fact, studies have shown that nicotine is usually the substance abuser’s first drug of abuse.

"It’s the substance where people learn how to do drugs;" McDonald said. "They learn how to cheat and how to steal, very often from picking up cigarettes that are someone else’s; from stealing cigarettes from family members or friends. They learn how to lie about their behavior, telling someone they have not been smoking.

"All of the behaviors that are characteristic of other substance abuse are present in the learning of how to use tobacco," continued McDonald.

When smoking is not addressed during inpatient addiction treatment, she said, several things are clear. Smoking breaks given to patients mimic other drug use by "stealing" time away from productive, normal activities; not quitting smoking is inconsistent with quitting all other substances of abuse; and continuing to smoke may trigger relapse.

Studies have shown that those who quit tobacco remain "clean and sober" longer, particularly with respect to alcohol abuse. Moreover, patients who go into treatment and do not smoke risk starting to smoke.

"I doubt if any addiction counselor," said McDonald, "has not seen a patient come to [his or her] unit a nonsmoker and leave a smoker."

Many things get in the way of substance abuse treatment facilities’ ability to address nicotine dependence in their programs. According to McDonald, contrary to recent studies, the culture of recovery advises waiting, fearing that people will relapse to other substances if they try to quite smoking at the same time. Insurance coverage for nicotine dependency, for most people, is either nonexistent or poor.

And there is a general lack of support to help programs become nicotine free. Administrators understand and support the rationale but fear the process and the potential outcome. Referral systems may tend to refer elsewhere if patients do not want to address tobacco, so the facility’s patient base may erode. Without the referral system’s support, a program’s transition to becoming nicotine free is all but impossible.

Many addiction-treatment staff oppose a transition to nicotine-free status, observed McDonald. James W. Mell, a certified addiction counselor, agrees. In an article he wrote for the May/June issue of Counselor, published by the National Association of Alcoholism and Drug Abuse Counselors, Mell outlines the difficulty that programs encounter from staff. "What turns treatment professionals into treatment antagonists?" Mell asks.

• Staff members may be addicted to nicotine themselves.

• Often staff lack appropriate, accurate information.

• Staff members often feel that addressing tobacco is just one more thing in their already overwhelmed day.

• Tobacco-using staff members, in recovery from other addictions, feel that their nicotine dependence will be viewed as discounting their time in recovery.

• Tobacco-using staff often feel that the focus of treatment is being turned away from the patients and onto them.

• Tobacco-using staff often feel that their jobs are in jeopardy.

At Thunder Road, McDonald managed the transition slowly but with definite goals and timelines. Although it took her more than four years to achieve the final goal of the staff’s being tobacco free, the process has proved beneficial.

"We learned a bit about how to deal with people’s reluctance, fear, and lack of knowledge about tobacco abuse," McDonald said. "We learned that it takes patience, lots of educational efforts, and simple time to modify these behaviors."

Only one staff methe transition; however, he didn’t specify the transition as the reason for leaving.

McDonald said that the endpoint was worth it. It is simply hypocritical for addiction-treatment staff to require the patients to address their addictions, if the staff are not free of addictive behavior themselves, she observed.

"It’s difficult to help others quit when you smoke yourself," she said. "In fact, your smoking can hurt the patients as they see your behavior and smell smoke on you. As a treatment professional, it sends entirely the wrong message."

Other treatment facilities in California are following McDonald’s lead. Facilities in New Jersey and Minnesota have also been pioneers in smoke-free addiction treatment.