Integrating tobacco dependence treatment and tobacco-free standards into addiction treatment: New Jersey's experience

Alcohol Research & Health, Fall, 2006 by Jonathan Foulds, Jill Williams, Bernice Order-Connors, Nancy Edwards, Martha Dwyer, Anna Kline, Douglas M. Ziedonis

Tobacco dependence is a serious and deadly problem for patients in treatment for alcohol and other drug (AOD) dependence. Such patients have increased mortality rates compared with the general population, and more than half die from tobacco-caused illnesses (Hurt et al. 1996). The majority of patients seeking treatment for substance use disorders state that cigarettes would be at least as hard or harder to quit compared with their primary problem substance (Kozlowski et al. 1989). Despite clear evidence of tobacco addiction, and major tobacco-caused health consequences among substance users, tobacco use traditionally has been minimized or ignored as an issue in addictions treatment settings. For example, AOD treatment facilities in the United States routinely ban alcohol and illicit drug use and drug dealing on their grounds; however, fewer than 1 in 10 ban tobacco use (Richter et al. 2005). These systems issues, in addition to biological, psychological, and other social factors, have resulted in extremely high tobacco use among patients in treatment for substance use disorders in the United States (70 to 95 percent), whereas smoking prevalence in the general population has fallen to less than 21 percent (CDC 2005).

New Jersey was the first State to require that all residential addiction treatment programs assess and treat patients for tobacco dependence and maintain tobacco-free facilities (including grounds). An evaluation of this policy change found that tobacco dependence treatment can be successfully integrated into residential substance abuse treatment programs through policy regulation, training, and the provision of nicotine replacement therapy (NRT) (Williams et al. 2005). Many other addiction treatment agencies (both residential and outpatient) around the country now have implemented or are planning to implement similar policies to ensure that their patients receive appropriate assessment and treatment of their tobacco dependence while receiving treatment for addiction to other substances. This paper aims to summarize the lessons learned from the experience in New Jersey.

History

Numerous agencies and individuals were involved in the preliminary work that led to the New Jersey policy change. Starting in 1991, the late Professor John Slade led a project funded by the Robert Wood Johnson Foundation called, "Addressing Tobacco in the Treatment of Other Addictions." This project trained New Jersey's addiction providers in tobacco treatment and provided the rationale that tobacco should be treated on par with other addictive substances in these settings. Many treatment providers were influenced by the project, and the Division of Addiction Services at the New Jersey State Department of Health and Senior Services provided additional funding. During the mid-1990s, addiction providers, the Division of Addiction Services, and individuals from the "Addressing Tobacco" project discussed the integration of tobacco into the divisions licensure standards. In 1999 the State of New Jersey passed licensure standards that required residential addiction treatment providers to assess and treat patients for tobacco dependence and maintain tobacco-free grounds at all residential treatment sites (with this later requirement phased in by November of 2001). By 2000 the Division was receiving funding for tobacco control from New Jerseys Comprehensive Tobacco Control Programs; some of this funding provided training and free NRT for residential addiction treatment providers to help implement the standards. The Tobacco Dependence Program at the University of Medicine and Dentistry of New Jersey (UMDNJ) School of Public Health administered the training and NRT.

The key ingredients for policy development and implementation in New Jersey were (1) a committed leader to "champion" this issue, (2) initial "buy-in" training to convince treatment providers that treating tobacco is the right thing to do, (3) willingness on the part of the State Division of Addiction Services to include the policy within the licensure standards for providers, (4) funding for training and NRT, and (5) availability of expertise in tobacco treatment and training.

Implementation and Results

Members of the addictions treatment community initially were concerned that clients in New Jersey would refuse to come to tobacco-free addiction treatment programs or be negatively impacted in some way by the policy. Staff members were concerned that the introduction of tobacco dependence treatment would possibly disrupt the treatment milieu and that the change to tobacco-free grounds would result in an increase in premature or irregular discharges from residential addictions treatment. To increase effective implementation, extensive training was provided on tobacco assessment and treatment for both management and front-line staff, and free NRT (in the form of nicotine patch and gum) was provided to all agencies for patient use (and later also for staff). New Jersey's Division of Addiction Services made an early decision to monitor the implementation and to enforce the new regulations through encouragement only. Usual disciplinary actions such as issuing a citation or revoking a license were not enacted for a failure to comply with the policy.