Hazelden, the world renowned treatment center in Minnesota, has decided to go entirely smoke-free at their treatment center. This includes all people on the grounds, including the staff and the residents who are there for treatment. Because Hazelden is seen as an industry leader, other treatment centers are likely to follow suit.

I work at a treatment center (not Hazelden), and I’m a recovering addict, and I’m also an ex-smoker, and I can firmly declare that this decision is a mistake.

Why is it a mistake? Let us count the ways:

A misleading study shows that forcing people to quit smoking improves overall outcomes

Photo by smokegirl_rebekah

A study done with 19 randomized trials showed how the addicts who were forced to quit smoking when undergoing substance abuse treatment actually fared better in achieving long term sobriety than the addicts who were allowed to continue smoking (some of them stayed quit from the cigarettes, too). Sounds good, right? Just force people in rehab to quit smoking, and their success rate goes up all around–for drugs and alcohol as well as for cigarettes. It’s win-win, you say!

Wrong. This is only half the story. First of all, these studies only considered people in rehab facilities who showed “willingness to consider quitting smoking.” This “willingness to quit” is in sharp contrast to the new policy, which is going to force those to quit who have no intention of doing so. It also does not include the struggling addicts who will refuse treatment altogether when faced with a smoke-free environment. I know for a fact that this is a critical factor for addicts in choosing a rehab, because I work at a rehab, and I answer the phone occasionally. Nearly everyone asks if it is a smoking facility, and then breathes a sigh of relief when I say that they are allowed to smoke in treatment.

In addition, most treatment centers are not locked facilities, and the clients can walk out freely if they so choose–and many of them will in the face of massive nicotine withdrawals. But understand that a smoke-free policy is going to prevent treatment in a lot of cases, period. The mere thought of giving up the cigarettes on top of drugs and alcohol is more than most people are willing to bear–so many of them will never make it to treatment at all.

Equating cigarettes with hard drugs and alcohol

The director of health services at Hazelden says “we want nicotine to be treated as one more drug of addiction.” Therefore, “treatment for nicotine will be integrated with the general individualized treatment plan for each patient.”

So Hazelden is going to start treating Nicotine the same way that they treat other, much harder drugs? This is a mistake for several reasons:

1) It sends a mixed message: people trying to kick heroin, alcohol, or cocaine should not be taught that Nicotine is an equivalent problem. It’s not. Even if cigarettes technically kill more people, that’s because far more people smoke than there are drug addicts and alcoholics.

2) Drugs and alcohol pose an immediate risk. Nicotine kills very slowly. Again, a mixed message that sends the wrong priorities. Are we really to believe that kicking cigarettes is just as important as not shooting street drugs with dirty needles? Which risk is more immediate? Which poses the greater danger in the short run? This should be obvious. Nicotine cessation is a suitable, long term goal for recovering addicts and alcoholics.

3) Including nicotine into a treatment plan will only serve to distract people from the immediate and necessary goal of recovering from drugs and alcohol (which can be an immediate, life threatening condition).

Photo by redmastadon

12 step programs are a mismatch for Nicotine dependence

Hazelden’s plan is to test their clients for Nicotine dependence, treat them with Nicotine replacement therapy (such as the patch), and then teach them the 12 step program for overcoming Nicotine addiction. This is the same 12 steps that they use for alcohol and drug addiction, only slightly modified to use the word “Nicotine.”

In my opinion, this doesn’t work.

The main reason that this doesn’t work is because the 12 steps are based on the unmanageability that is acknowledged in the first step. The whole program hinges on the idea that your life is out of control and that you are completely unmanageable and that you need a higher power to turn to for help. Regarding drugs and alcohol, this idea works great.

Regarding cigarettes, this idea is ridiculous.

Smoking cigarettes does not have the immediate consequences of, say, drunk driving. Cigarettes do not have the immediate, life-devastating effects that a heroin overdose has on someone. Each individual cigarette is harmless. Yes, they will eventually kill you. Tomorrow or the next day. But alcohol and crack and heroin and all that other stuff will ruin your life today. They can put you in prison at the drop of a hat, or kill you instantly with an overdose. That’s unmanageability. Cigarettes addiction isn’t like that, so the 12 step philosophy doesn’t work quite as effectively when dealing with them.

Now it is true that for some smokers, the 12 step program works great for their Nicotine addiction. This is fine. But for the struggling addict or alcoholic who is fighting for their life, using the same 12 step program on their cigarette addiction is another mixed message. Also, what will happen when the addict leaves treatment and immediately returns to smoking (as they very well might have planned on doing in the beginning), and then sees that the 12 step program has failed for their cigarette addiction? This might cause them to give up hope in battling against drugs and alcohol to some degree. While some of this is speculative, consider the difference between a relapse on cigarettes, versus a life-threatening relapse on drugs and alcohol.

And finally…

The recommendation to go smoke free comes from Ken Winters, PHD, of the substance abuse facility for adolescents.

Think about this now. How long have these adolescents been smoking? Not so long. The decision about whether or not to go smoke-free should be based on the average age of those in treatment–much closer to middle aged adults, who are no doubt much more heavily dependent on nicotine.

For treatment to be effective, you have to

1) Get people to come to the treatment center, and
2) Keep them there long enough to teach them how to recover

This involves keeping them at least somewhat comfortable. Quitting smoking is not comfortable, period. Under any circumstances.

Indeed, some addicts will keep using hard drugs rather than face even the thought of treatment without cigarettes.

What do you think? Should treatment centers force their clients to quit smoking as well?