Nicotine Use and Recovery
By Kevin Doyle, EdD
NOTE: This was originally published for the Hazelden Betty Ford Foundation’s monthly Recovery Advocacy Update. If you’d like to receive our advocacy emails, subscribe today.
A colleague and I recently had a spirited discussion with a person in long-term recovery from alcohol use disorder, who is also a staunch advocate of substance use disorder (SUD) treatment programs requiring patients to abstain from nicotine while in treatment and offering services to support them in adhering to that requirement.
It certainly makes sense to try to address tobacco use disorder (the terminology from our diagnostic manual, the DSM-5) concurrently with other SUDs. And residential treatment providers have a “captive audience” that represents a unique opportunity to do so. The reality, though, is much more complicated.
Let me note that as a non-smoker myself, I have no personal stake in this issue and have both monitored it and struggled with it for over three decades in a variety of roles at treatment programs with different populations and levels of care. It is an emotional topic for many.
On the “pro” side (that is, allowing smoking or nicotine use during SUD treatment), many argue that patients deserve to choose, and that requiring people to abstain from nicotine will dissuade some from seeking treatment in the first place. There’s also the reality that people do not die in acute ways (like overdose) from smoking (chronic use is another matter), and that they rarely seek or are referred to treatment due to nicotine. Then there is the other reality than many people are able to remain abstinent from alcohol and other so-called mood-altering drugs while continuing to smoke, vape or chew tobacco. Let’s not forget the issue of the staff, some of whom may be smokers: how do you manage that?
Logical arguments, of course, exist on the other side of the discussion as well. Most notably: research does seem to support higher recovery rates for those who also abstain from nicotine. However, it is unclear in the research if treatment dropout rates are also higher or if such a requirement does actually discourage people from seeking treatment in the first place. There’s also the reality that cigarette smoking is the leading cause of preventable death in the United States. From a common-sense perspective, why would a treatment program allow the use of a drug that contributes to 500,000 deaths annually?
At minimum, it would seem that any program mandating a nicotine-free environment should provide a wide range of treatment and cessation options, from Nicotine Anonmyous groups to nicotine replacements (i.e. patch or gum) to medications such as Chantix and Wellbutrin, under appropriate medical supervision.
What troubles me most is when patients start to smoke (or greatly increase their smoking) while participating in treatment for another substance use disorder. One may hear something like: “I wanted to hang out with the other patients on breaks, and they were all in the smoking area, so I started smoking as well.” This seems not only wrong, but also somewhat irresponsible on the part of the treatment provider.
Two other issues are worth considering here as well.
One is that the discussion above has been framed in terms of residential treatment. What about outpatient treatment— should patients in outpatient settings be mandated to abstain from nicotine? The other issue — relevant to all levels of care — is how do you enforce a nicotine-free environment? How onerous and distracting from the core of care would it be to police such a policy? It seems especially excessive to dismiss someone for smoking a cigarette, a practice that should be avoided when patients return to using any substance. As psychiatrist David Mee-Lee has said so eloquently, instances such as these should be dealt with “by adjusting the treatment plan,” not by imposing draconian, punitive measures like “kicking someone out” of treatment. We must remember that now, more than ever, dismissing someone from treatment may put them at risk of overdose and take away their only opportunity to receive such critical care.
Regardless of where one falls in this discussion, there appears to be common ground on which we can all agree:
- Treatment programs should provide resources for their patients who have tobacco use disorders (as it is called in our diagnostic manual, the DSM-5);
- Clinicians should be thorough in their assessments and diagnostic work and ensure that patients with tobacco use issues are provided with accurate diagnoses; and
- Throughout all of their programming, treatment programs should thoroughly educate patients about the benefits of addressing/stopping nicotine use right along with the rest of their substance use.
Kevin Doyle Ed.D., is the president and CEO of the Hazelden Betty Ford Graduate School of Addiction Studies in Center City, Minn.
