3 This training was developed by the Professional Development Program, under a contract with the NYS Department of Health, Tobacco Control Program. PDP developed five classroom-based curricula and seven online modules, which are available at www.tobaccorecovery.org www.tobaccorecovery.org
4 Housekeeping Hours of Training Breaks and Restrooms Tobacco Use Policy Cell Phones Active Participation Complete Training Evaluation
10 PM 12 Attitudes and Beliefs The purpose of this activity is to help you explore your attitudes and beliefs about: Tobacco use Integrating tobacco interventions into chemical dependence services Tobacco use, dependence, and recovery
11 PM 12 Attitudes and Beliefs, cont’d Debrief and Process
12 PM 13 Timeline 1798 – 1970s: Recognition of Tobacco Dependence - Lost and Found1798 – 1970s: Recognition of Tobacco Dependence - Lost and Found 1980s - 1990s: Emerging Awareness 1980s - 1990s: Emerging Awareness 2003 - 2008: A New Century
RECOGNITION OF TOBACCO DEPENDENCE Lost and Found 1870s late 1800s, early 1900s 1930s1960s-1970s 13 PM 13 1798
1798: Benjamin Rush, a physician and signer of the Declaration of Independence, identifies tobacco use as a harmful substance and observes that use supports excess alcohol consumption. RECOGNITION OF TOBACCO DEPENDENCE 1870slate 1800s, early 1900s 1930s1960s-1970s 14 PM 13 1798
1870s: Tobacco is identified as both a harmful addictive substance and as contributing factor in relapse from alcoholism and drug dependence. RECOGNITION OF TOBACCO DEPENDENCE 1798late 1800s, early 1900s 1930s1960s-1970s 15 PM 13 1870s
Late 1800s and early 1900s: Tobacco dependence is routinely treated along with alcoholism and other drug dependence in inebriate clinics and asylums. RECOGNITION OF TOBACCO DEPENDENCE 1870slate 1800s, early 1900s 1930s1960s-1970s 16 PM 13 1798
RECOGNITION OF TOBACCO DEPENDENCE 1870slate 1800s, early 1900s 1930s1960s-1970s 1930s - Oxford Group principles used to help support early recovery efforts; Oxford Group frowns on tobacco use. 1935: Beginning of Alcoholics Anonymous. Alcoholism counseling begins to evolve. Tobacco use becomes embedded in recovery practices and the recognition as a serious addiction and recovery issue is lost for many years. 17 PM 13 1798
RECOGNITION OF TOBACCO DEPENDENCE 1870s late 1800s, early 1900s 1930s1960-1970s 1964: Surgeon General Report on Smoking and Health indentifies the adverse health effects of tobacco use. 18 PM 13 1960s: Alcoholism counseling continues to evolve. 1970s: Many former drug users become drug abuse counselors. Most counselors in both groups use tobacco.
EMERGING AWARENESS 198519921996 1985: Geraldine Delaney, founder of Little Hill-Alina Lodge in New Jersey, makes this the first tobacco-free chemical dependence treatment program. 20 PM 14
EMERGING AWARENESS 198519921996 1992: John Slade, M.D. begins the Addressing Tobacco in the Treatment of Other Addictions Project at the University of Medicine and Dentistry of New Jersey (UMDNJ) 21 PM 14
EMERGING AWARENESS 198519921996 -1997 1996: Van Dyke and Norris Addiction Treatment Centers (ATC) become the first tobacco- free chemical dependence inpatient treatment programs in New York State. Stutzman ATC follows in 1997. 22 PM 14
A NEW CENTURY 200320042005200620072008 23 PM 15 2009
A NEW CENTURY 2003: Passage of NYS Clean Indoor Air Act, which exempts substance abuse and mental health treatment programs. 2003: American Cancer Society and ASAP of NYS create a mission statement to promote tobacco-free chemical dependence programs. OASAS task force convenes to discuss tobacco regulations and resources. 2003: NYS Partnership for the Treatment and Prevention of Tobacco Dependence convenes. 200320042005200620072008 24 PM 15 2009
A NEW CENTURY 2004: Founding of Tobacco Recovery Coalition of the Capital District, Albany, NY. 2004: OASAS Commissioner William Gorman Policy Statement that stated: Prevention and treatment providers should address all addictions including nicotine. 200320042005200620072008 25 PM 15 2009
A NEW CENTURY 2005: All 13 OASAS-operated Addiction Treatment Centers (ATCs) in transition to be tobacco-free programs. August 2005: OASAS Medical Director letter to all OASAS certified providers: “Addiction providers are best positioned to help patients become tobacco free to increase the quality of their lives in recovery.” 2005: Some NYS chemical dependence providers begin implementing similar policies, becoming tobacco-free agencies 200320042005200620072008 26 PM 16 2009
A NEW CENTURY May 2006: ASAP opens NYS Tobacco Dependence Resource Center. November 2006: ASAP launches www.tobaccodependence.org. December 2006: OASAS releases Local Services Bulletin No. 2006 – 10: Tobacco Dependence Practice Guidelines. 200320042005200620072008 27 PM 16 2009
A NEW CENTURY July 2007: OASAS Commissioner, Karen Carpenter-Palumbo - Announcement of Regulation Part 856 Tobacco-Free Services, to be effective by July 24, 2008. ASAP Questions and Answers about Tobacco-Free Chemical Dependence Services teleconference series begins. August 2007: NY Tobacco Control Program issues RFP to provide statewide training and technical assistance to integrate tobacco interventions into services. September 2007: TCP starts providing $4M in Over-the-Counter Nicotine Replacement Therapy (OTC NRT) products to Patients and Staff of OASAS programs. 200320042005200620072008 28 PM 16 2009
A NEW CENTURY January 2008: TCP awards training and technical assistance contract to Professional Development Program, University at Albany. March - July 2008: PDP begins training and technical assistance, launches www.tobaccorecovery.org website, selects Regional Training Centers, designs Modules 1 and 2, and begins statewide training. July 24, 2008: OASAS Regulation Part 856 Tobacco-Free Services goes into effect. 200320042005200620072008 29 PM 16 2009 October - December 2008: PDP launches Module 3 and Online Modules 1 and 2.
A NEW CENTURY January – December 2009: PDP launches Modules 4 – 5, Online Modules 3 – 7, and completes statewide classroom training. 2009: Family Smoking Prevention and Tobacco Control Act enacted. The FDA is finally given the legal authority to regulate tobacco, nicotine levels, and tobacco additives, excluding menthol. States of Washington and Texas: decide to implement tobacco- free addiction treatment services. 200320042005200620072008 30 PM 16 2009
32 PM 17 Mission and Purpose Treating tobacco dependence is consistent with the mission and purpose of chemical dependence services
33 PM 17 Mission Statement Example “We provide quality, cost-effective care to those suffering from alcoholism and chemical dependency and to the many whose lives are affected by the diseases of addiction.”
34 PM 17 Mission Statement Example 2 “ Our mission is to provide a quality continuum of comprehensive treatment and related services, in a caring atmosphere and at a reasonable price, for all people experiencing problems with alcohol or other drug use.”
35 PM 17 Skills and Knowledge Treating tobacco dependence requires the same skills and knowledge that addiction professionals already have to treat chemical dependence
36 PM 18 Tobacco’s Relationship to Alcohol and Other Drugs Prevalence of Tobacco Use (National Data) General Population19.8% Addiction Treatment60 – 95% Serious Mental Illness75 – 80% HIV and AIDS50 – 70%
37 PM 18 -19 Tobacco Use 7 Days Prior To Admission in 2006 Level of Care% Using% Males% Females Intensive Residential 76 % 74 % 82% Community Residential 73% 71% 80% Supportive Living 81% 79% 84% Inpatient Rehabilitation 80% 79% 82% Outpatient Clinic 63% 65% Outpatient Rehab 77% 76% 79% Methadone Clinic 83% 82% 84% Data: 2006, OASAS Certified Programs
41 PM 20 Tobacco Industry Practices Knowingly sells a product that when used as intended causes serious disease and death Targets youth and denies doing so Lots of money and no morals Continues to lobby against further tobacco regulation Uses massive advertising campaigns, plus insidious and deceptive marketing
42 PM 21 Toll of Tobacco Use General Population - Annually Deaths over 438,000 Health care and productivity cost $194.3 billion
43 PM 21 Toll of Tobacco Use Tobacco-Related Deaths are greater than Alcohol or Drug-Related Deaths among people treated for chemical dependence
44 PM 21 Toll of Tobacco Use Bill W. Dr. Bob Marty Mann
45 PM 22 Toll of Tobacco Use For every person who dies from their tobacco use, there are twenty people living with serious health problems caused by their tobacco use.
46 PM 22 -23 Toll of Tobacco Use Tobacco-Related Health Consequences: Commonly known Less commonly known
49 PM 28 Tobacco Dependence Why do people use tobacco?
50 PM 28 Tobacco Dependence (cont’d) Nicotine Dependence vs. Tobacco Dependence DSM III / III-R used the term “tobacco dependence.” Why did this change to “nicotine dependence” in the DSM-IV / DSM IV-TR?
51 PM 29 Nicotine dependence compared to cocaine and amphetamine dependence nicotine ACh amphetamine cocaine DA
53 PM 31 DSM-IV-TR Criteria Nicotine dependence criteria is not unique or different DSM-IV-TR substance dependence criteria is used for diagnosing nicotine dependence (a.k.a. tobacco dependence)
54 PM 32 DSM-IV-TR Criteria, cont’d Nicotine Withdrawal Daily use for several weeks Cessation is followed within 24 hours by four or more physical or behavioral signs. Symptoms causes significant distress and impairment and are not due to medical condition or other mental disorder
55 PM 33 - 34 Tobacco Dependence Treatment Management of withdrawal is critical to successful recovery Strong evidence of medication effectiveness Medication effective for many populations Insufficient evidence of effectiveness only with a few populations
56 PM 35 - 36 Tobacco Dependence Treatment (cont’d) First-Line medications Nicotine Replacement Therapy (NRT) Non-nicotine medications Combination of medications is best Other medication levels may be affected after stopping tobacco use Few medical contraindications
57 PM 37 Tobacco Dependence Treatment (cont’d) Supportive Counseling The combination of counseling and medication is more effective than either alone Motivational Interviewing, Cognitive Behavioral Therapy, Skills Training, and Relapse Prevention Therapy are all effective
58 PM 37 Summary - Nicotine Replacement Therapy Nicotine medications have wide margin of safety Dose should be at least equivalent to tobacco use Combining tobacco medications is more effective Patients with other chemical dependencies may require higher dosage and longer term NRT Under-dosing may not manage withdrawal symptoms and often results in relapse
59 PM 38 Comparison of Nicotine Delivery Diagram shows rise in nicotine levels in plasma after smoking a cigarette and after using different nicotine replacement therapy products (Adapted from Royal College of Physicians Website, per MAH Russell,1987 Nicotine intake and its regulation by smokers)
60 PM 39 The Cigarette: A Perfect Drug Delivery Device Cigarettes - highly engineered nicotine delivery device 1 cigarette can peak the nicotine blood level 5- 7x higher than the effect of a 21mg nicotine patch 300 hits per 1 ½ pack of cigarettes Exact Titration: frequency of use, intensity, and ability to fine tune delivery of nicotine
61 PM 39 The Cigarette: A Perfect Drug Delivery Device (cont’d) Allows exact dosing by user Severely addicted smokers and those with limited income often re-light Menthol cigarettes – allows deeper inhalation using less cigarettes to achieve higher nicotine levels
62 PM 40 How Tobacco Dependence Differs from AOD Dependence Tobacco use does not cause intoxication Tobacco use generally does not cause adverse behavioral outcomes Tobacco use does not produce intense euphoria Tobacco use may minor perceived improvements in cognitive functioning and mood
63 PM 40 How Tobacco Dependence is Similar to AOD Dependence Affects release of dopamine and other neurotransmitters in the brain Continued use despite serious harmful effects Withdrawal syndrome Rapid rates of relapse after attempts to stop Nicotine self-administration in animal studies
64 PM 41 Reframing Language Public Health Terminology smoking smoker quit date cessation Recovery Terminology
65 PM 42 - 43 Challenges in Treating Tobacco Dependence Nicotine has strong negative and positive reinforcement Nicotine has some perceived beneficial effects Smoking tobacco provides most intense reward effects Nicotine is not intoxicating Nicotine withdrawal
67 PM 45 What is the OASAS regulation? What is expected of: Patients Staff and Volunteers Program Administrators Part 856 Tobacco-Free Services
68 PM 46 -47 OASAS Regulation effective July 24, 2008 Requires all OASAS certified and funded programs to “determine and establish written policies, procedures and methods governing the provision of a tobacco-free environment.” - Section 856.5 (a) Part 856 Tobacco-Free Services (cont’d)
69 PM 48 Tobacco-Free: No use of tobacco products in a program’s facilities, grounds or vehicles owned by or under the control of the program Facility: The space used by the program’s patients, staff, volunteers, and visitors Limited to space “under the direct control” of the program - Section 856.4 Tobacco-Free Environment
70 PM 49 Define the facilities, vehicles and grounds. Prohibit patients and visitors from bringing tobacco products and paraphernalia to the program. Notify patients, staff, volunteers and visitors of the policy in writing. Prohibit staff from using tobacco products while at work, during work hours. Minimum Policy Requirements
71 PM 49 Establish tobacco-free policy for staff while on the work site. Establish treatment modalities for patients who use tobacco. Describe tobacco training available to all staff. Describe tobacco prevention and education programs available to patients, staff, volunteers, and others. Minimum Policy Requirements (cont’d)
72 PM 49 Establish procedures to address patient tobacco relapse. “… every effort shall be made to provide appropriate treatment services…” Establish procedures to address staff tobacco “relapse consistent with the employment procedure…” - Section 856.5 Minimum Policy Requirements (cont’d)
73 PM 50 Patients, staff, volunteers, and visitors may not use tobacco on program’s buildings, grounds, and vehicles. Patients, family members, and other visitors may not bring tobacco or paraphernalia to the program. Staff may not use tobacco products at work, during work hours. Implications of the Regulation
74 PM 50 Write a tobacco-free environment policy. Post notices and provide policy to all patients, staff, volunteers, and visitors. Identify tobacco prevention and education programs available to patients, staff, volunteers, and visitors. Establish treatment modalities for patients who use tobacco. Program Administrator Responsibilities
75 PM 50 Identify tobacco use and dependence training available for staff and volunteers. Establish procedures for patient and staff policy violations. Manage organization’s change process. Program Administrator Responsibilities
76 PM 51 Regulation 856 – True or False? Patients, family members, or other visitors may not bring tobacco or tobacco paraphernalia to the program or service.
77 PM 51 Regulation 856 – True or False? OASAS-funded Permanent Supportive Housing and Vocational Rehabilitation programs are exempt from the regulation.
78 PM 51 Regulation 856 – True or False? Staff may use tobacco during work hours, while on break, and off premises.
79 PM 51 Regulation 856 – True or False? For residential treatment programs, patients who relapse on tobacco must be administratively discharged.
80 PM 51 Regulation 856 – True or False? For outpatient treatment programs, all patients must stop using tobacco for the duration of their treatment.