Our Unconscious Relationship with Tobacco

March 11, 2022

In the first part of this article, I’ll note one particular barrier I have heard expressed about the idea of changing an addiction treatment campus to “tobacco-free” or to the idea of a tobacco-free model of care. And then I’ll discuss a few responses to that barrier.

In the second part of the article, I’ll provide a list of some possible reasons why 480,000 deaths¹ a year due to smoking don’t get our attention and don’t cause us to adopt a smoke-free model of addiction treatment.

PART 1: One particular barrier, and some responses to that barrier.

One Particular Barrier

The organization where I work made the switch² to a tobacco-free campus back in 2013. From time to time after we made that change, I’ve been asked an interesting question. The question comes in a few different versions, and it points to one particular barrier against making the change to a tobacco-free addiction treatment method and campus.

Here are the two most common versions of the question:

“Isn’t it the person’s right to smoke cigarettes?”
“But isn’t smoking cigarettes a human right?”

Interestingly, every time I have been asked any version of this question it has been asked of me by people with clinical careers in community agencies providing addiction treatment and mental health counseling services or related human service help.

On the topic of tobacco, it seems as if the professional part of our field knows the right answer but keeps walking in the wrong direction.

I wanted to share a few of my responses to that question, in no particular order.

Response #1: Treating One Addiction While Ignoring Another

In this reply I ask what it even means to claim to provide “addiction treatment” and yet treat one addiction while ignoring another.

One question of my own that I’ve used as a probe of our intent as addiction professionals is:

“If a person we treated for alcoholism dies of emphysema due to continuing smoking cigarettes, did we really treat their disease, or just an alcohol use disorder?”

We all know the standard response to that challenge is, “We don’t ignore cigarette smoking”. And in this context the other response that “…addiction isn’t really a disease…” is outside the meaning of the question.

Rather than contend with the point of my probe, some will state their…

use of motivational interviewing, NRT’s, patient education, and a tobacco-specific group; or
inclusion of tobacco as a part of the patient’s clinical assignments or homework.

But I’d like to state that if it was cocaine or methamphetamine the patient was smoking instead of cigarettes, we would likely not be so lackadaisical or cavalier.

Response #2: Do No Harm

Another response I give at times is one concerning “Do no harm.”

Addiction professionals with clinical credentials have a clinical duty to those we serve. Among those duties we are to:

Not do harm to those we serve
Provide an atmosphere or environment of care that does not harm any patient

Even if it was the human right of one person to smoke cigarettes, would that one person’s right within their personal space and life remove our responsibility to anyone else or everyone else we serve in our clinical setting? Would we be willing to harm all within our setting for the sake of the freedom of one?

My current view of this challenge is that it pits the personal freedom of a smoker against the patient rights of someone else who is seeking services. That is, a smoker does have a personal freedom to smoke. But a different person seeking services in the same setting has a patient right to a smoke-free environment. My view is that at an SUD treatment providing organization, the freedom of one person to smoke ends at the line of the rights of others to access care in a smoke-free environment.

Response #3: The Right to Slowly Die

I usually don’t include any part of this third possible reply, but I’ll present it here regardless.

When I include this, I start by acknowledging the value of the question concerning the individual and their human right to smoke cigarettes. I state that the question is simple, good, and powerful – at the surface level. And I affirm that yes, it is the person’s human right to smoke cigarettes.

And then I introduce the idea that there are potentially complicating matters of law, ethics, and morals. And that similarly, these matters can be phrased as questions as well.

Examples within each category follow.

Law: Is the person legally permitted to purchase, possess, and smoke cigarettes, or are they under-age?
Ethics: Has the patient been asked to sign a “Do Not Resuscitate” order in case of heart attack or stroke while they continue to smoke under our care? Have we offered transfer to an “Addiction Hospice” type of SUD care if such a program exists nearby, where dying slowly is the pre-determined plan? Do we realize the implications of the care we do provide and do not provide, and discuss those plainly in our informed consent?
Morals: Do we offer our staff the standard “Exception From Care” option on smoking-related tasks, and make the related reasonable accommodations? I remind them that “exception from care” is a standard in place so that staff are not required to violate their conscience or personal sense of morality. And I link this standard to the topic of tobacco-free treatment by asking if staff have the Exception From Care option on tasks that require them to actively support or under-treat tobacco smoking as a job function while they are working in addiction treatment?

More to the point, does the patient have a right to die slowly while we watch?

If it was any other disease, we would do a wellness check, or call an ambulance, or have the person who is allowing themselves to die involuntarily committed as a danger to themselves.

Response #4: Choosing a Human Right or Enacting a Loss of Control?

In this response I note that while picking up their first cigarette ever, the person might have been exercising a choice to smoke.

But to the extent the person now:

has a persistent desire or inability to cut down or quit smoking
experiences cravings and urges to smoke
is losing role function or areas of life due to use
experiences withdrawal when they don’t smoke…

…it might be that they are not choosing freely but are experiencing a loss of control. And personally, I differentiate loss of control from the notion of a personal freedom.

PART 2: Some possible reasons 480,000 deaths per year due to smoking don’t get our attention or lead to change.

To develop a partial list of some possible reasons our field does not adopt a smoke-free model of treatment, I’ve borrowed some notions from an article³ and applied them to this topic. Below is a list the reader could review toward identifying barriers to this change.

Possibilities might include:

Allowing smoking is a “residue of the somatic process” still present in organizational leaders, who are current or former smokers.
Leaders in addiction treatment providing organizations are relatively unaware of how they look on this topic from the outside.
Leaders in addiction treatment organizations do not discuss their lack of change on this topic in a meaningful way with those outside their organization and prefer to keep it unacknowledged on the social dimension.
Leaders in addiction treatment organizations take their cues from other leaders in the field; they see other leaders are doing nothing, assume those leaders are thoughtful and intentional, and thus also do nothing.
Workers and leaders in addiction treatment organizations have a special hindrance that if not present would allow them to obtain a true knowledge of this topic.
Workers and leaders in addiction treatment organizations, seeking to remain comfortable, enact the process of addiction by allowing it in others, disavow that fact, and attend only to their work tasks.
When the voice that emanates from within shines light on this matter, that voice is censored, serving to keep the thing out of awareness.
The charge for personal wellbeing, within organizational leaders, is neither held at the whole person level nor allowed to work progressively over time – but is merely localized within them; thus, their leadership in their own organization is localized by topic.
Fear of the smoke-free idea, based on fear of the image others would see if the idea was adopted, based on fear of presenting that new and different way of operating to the world at large – and doing passionate self-preservation instead.
Understanding the smoke-free idea, but not feeling the idea.
Maintaining the topic at the border between acknowledgment and unawareness.
The choice to not acknowledge smoking and to take on the problems associated with that choice is preferred over the problems associated with the choice of addressing smoking.
Maintaining treatment as usual – in its service as a phobic outer structure for an unacknowledged worry.
The deep knowing that the smoke free approach is the best in reality – but that knowledge is exempted from consideration given the timeless lessons that have taught us avoidance.
A certain inherited view of making this change, and long ago leaving the idea of this change discarded and unserviceable.
Adhering to the precious approach with a stilted explanation that does not permit this change.
Isolation from those that discuss this change with words rather than with emotions and the ideas related to those emotions.

Conclusion: Raising Doubts About Not Changing

We learn in motivational interviewing that raising doubts about the lack of change can help tip the decisional balance. And we learn that providing information can help accomplish that some of the time. Thus, I’ll conclude by providing some information and related resources.

“Tobacco use is the leading preventable cause of death in the United States”.⁴

“Cigarette smoking causes about one of every five deaths in the United States each year.”⁴

Smoking is associated with 5 times the risk of relapse 3 years later.⁵

Severity of nicotine dependence is associated with higher craving in alcohol-dependent patients. This suggests shared pathophysiological mechanisms in alcohol craving and nicotine dependence.⁶

Tobacco use is correlated with relapse. Addressing tobacco in treatment improves outcomes.⁷

So, what are some reasons to address tobacco use in addiction treatment settings? And why change to a tobacco-free model of addiction treatment?

High rates of tobacco use in individuals being treated for other substance use disorders
Greater morbidity and mortality in individuals who use tobacco and other substances
Higher relapse rates in patients who do not stop using tobacco
Patient and staff exposure to second-hand smoke
Increased risk of new tobacco use, in non-tobacco using patients

In our organizational change process, we went through stages of change over a series of years as an organization. Eventually, we made the decision, including a decision at the emotional level, to get in alignment with both our own values and the evidence – to treat the core disease.

And in so doing, we recognized that cessation might be little more than an attempt to control one’s tobacco use disorder (and that quitting would be diagnostic, not prognostic). And so, we decided to not use a cessation framework, but to use a wellbeing or recovery framework instead.

References

The references are provided in a clickable format for your convenience.

¹CDC Tobacco Statistics

²Coon, B. (2014). An Addiction Treatment Campus Goes Tobacco-Free: Lessons Learned. Addiction Professional. 12(1): 18-20.

³Freud, S. (1915). The Unconscious. SE14: 159-215.

⁴CDC Tobacco-Related Mortality

⁵Weinberger, A. H., Platt, J., Esan, H., Galea, S., Erlich, D., & Goodwin, R. D. (2017). Cigarette Smoking Is Associated With Increased Risk of Substance Use Disorder Relapse: A Nationally Representative, Prospective Longitudinal Investigation. The Journal of Clinical Psychiatry. 78(2), e152–e160.

⁶Hillemacher T, Bayerlein K, Wilhelm J, Frieling H, Thürauf N, Ziegenbein M, Kornhuber J, & Bleich S. (2006). Nicotine Dependence Is Associated With Compulsive Alcohol Craving. Addiction. 101(6):892-7.

⁷ Stuyt, E. B. (2015). Enforced Abstinence from Tobacco During In-Patient Dual-Diagnosis Treatment Improves Substance Abuse Treatment Outcomes in Smokers. The American Journal on Addictions. 24(3): 252-257.

Recommended Reading

Fiore, M. C., Jaén, C. R., Baker, T. B., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service.

Goodheart, C. D. & Lansing, M. H. (1997). Treating People With Chronic Disease: A Psychological Guide. American Psychological Association.

Hilton T. F. & White W. L. (2013). Why Does the Addiction Treatment Field Continue to Tolerate Smoking Instead of Treating It? Counselor. 14:34-7.

Knudsen, H. K. & White W. L. (2012). Smoking Cessation Services in Addiction Treatment: Challenges for Organizations and the Counseling Workforce. Counselor. 13:10-4.

McKelvey, K., Thrul, J. & Ramo, D. (2017). Impact of Quitting Smoking and Smoking Cessation Treatment on Substance Use Outcomes: An updated and narrative review. Addictive Behaviors. 65:161-170.

U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking – 50 Years of Progress. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.