Virtually any innovation at Hazelden's Center for Youth and Families in Plymouth, Minn., is intended to improve outcomes for its young patients, and that's why the center became completely tobacco-free on Jan. 1 of this year. The change to totally smoke-free grounds means there is no smoking on the 15-acre campus for patients, staff and visitors. The smoke-free policy is accompanied by enhanced tobacco cessation efforts for patients.

"Research suggests that treating nicotine addiction concurrently with addiction to alcohol and other drugs will achieve improved outcomes," said Jim Steinhagen, executive director of the Center for Youth and Families.

Steinhagen said the change was made to more effectively meet state regulatory statutes and was based on research that dispels the myth that tobacco cessation impedes successful addiction treatment outcomes. The smoke-free policy was made at the recommendation of Ken Winters, PhD, director of the Center for Adolescent Substance Abuse Research at the University of Minnesota and a Hazelden consultant. "If we want to continue to be one of the best of the best, Dr. Winters recommended a smoke-free campus and that we treat nicotine addiction concurrently with alcohol and other drug addiction," said Steinhagen.

Long-term abstinence improves
The majority of research indicates that smoking cessation is unlikely to compromise alcohol and other drug use outcomes, according to Steinhagen. In fact, in a meta-analysis, J. L. Prochaska and colleagues (Journal of Consulting and Clinical Psychology 72:1144-1156,2004) evaluated the outcomes of smoking cessation interventions in 19 randomized controlled trials with people in addiction treatment or recovery. At the end of treatment, no differences in substance use outcomes were found between patients who engaged in smoking cessation treatment and those who did not. What's more, at long-term follow-up, participation in a smoking cessation intervention provided during substance abuse treatment was associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs. A comprehensive research review on this topic was recently published by NIAAA ("Alcohol and Tobacco: An Update." Alcohol Research & Health 29(3);2006).

In addition, there are long-term health benefits to treating tobacco concurrently with other substance abuse. For instance, more alcoholics die of tobacco-related illness than die of alcohol-related problems, according to a study by Richard Hurt, MD, and colleagues at the Mayo Clinic ("Mortality following inpatient addictions treatment." Journal of the American Medical Association, 275:1097-1103,1996).

Tobacco cessation efforts enhanced
Tobacco cessation efforts for young people at the Center for Youth and Families have been improved. Prior to the smoking ban, all patients at the center attended a session on nicotine cessation and were assessed for nicotine dependence. Patients under 18 who were assessed as nicotine dependent were required to attend a smoking cessation group, while this group was optional for patients 18 and over. Now the new cessation program makes tobacco cessation efforts mandatory for all patients who meet the criteria for nicotine dependence.

The evidence-based Modified Fagerstrom Test for Nicotine Dependence is administered to all patients to test for nicotine dependence. If a patient has significant withdrawal, the Minnesota Withdrawal Scale is administered to assess the need for nicotine replacement. Nicotine replacement therapy may be employed, and appropriate pharmacological interventions may be prescribed as an anti-craving medication for heavy nicotine users (1.5 packs a day or more).

"Treatment for nicotine dependence will be integrated with the general individualized treatment plan for each patient," said Ariel Johanna Cohen, director of Health Services for the Center for Youth and Families and the leader of a Tobacco Cessation Team that developed new policies to support the tobacco-free campus. "We want nicotine to be treated as one more drug of addiction," she said.

A tobacco treatment counselor, Hillary Hittner, is assigned to nicotine-addicted patients and collaborates with the patient's clinical case manager. Twelve Step work, lectures and education specific to nicotine addiction, and one-on-one counseling are part of the tobacco cessation efforts. When patients leave the center, tools and resources for continued abstinence from tobacco are provided. Quit-smoking programs have been offered to staff as well during the transition to a smoke-free campus.

"We think it's a good thing [to treat nicotine dependence concurrently], and it is supported by research," said Cohen. "We know it increases the chances for complete recovery."

Cohen adds that "in the world of recovery, we all need to look at nicotine addiction and take it seriously."

The Center for Youth and Families' smoke-free plan is considered a big step in Hazelden's exploration to expand smoking cessation efforts in other locations. Other Hazelden locations currently are not totally smoke-free--they permit smoking outdoors in designated areas--and they offer help to patients wanting to quit tobacco.

Published in The Voice, Winter 2008