addressing tobacco in the treatment of other addictions: the nj experience

1. Addressing Tobacco in the Treatment of Other Addictions:The NJ Experience Bernice Order-Connors Tobacco Dependence Program UMDNJ School of Public Health

3. Why address tobacco? Substance abusers are more likely to smoke cigarettes than the general population and they are more likely to be nicotine dependent (Richter, 2002) Smokers receiving inpatient treatment for alcoholism or other non-nicotine drugs are more likely to die of tobacco-caused illness than by the drug they are receiving inpatient treatment for (Hurt et al, 1996)

4. Addiction Programs as Clients Inpatient Short-term Detox Hospital-based Residential Therapeutic Community Partial Hospital Outpatient Intensive Outpatient Halfway House Three-quarter house MICA Methadone Faith-based Shelter

5. In November 1999, New Jersey established Tobacco Standards for Licensure (NJAC 8:42A) These required residential addictions programs to provide clients with tobacco assessment and treatment planning, prohibiting tobacco products within all buildings and on the grounds of freestanding residential substance abuse treatment facilities. Full implementation by November 15, 2001. The state provided free nicotine patches and gum to clients in these settings In November 1999, New Jersey established Tobacco Standards for Licensure (NJAC 8:42A) These required residential addictions programs to provide clients with tobacco assessment and treatment planning, prohibiting tobacco products within all buildings and on the grounds of freestanding residential substance abuse treatment facilities. Full implementation by November 15, 2001. The state provided free nicotine patches and gum to clients in these settings

6. Preparing for Standards Implementation (09-11/01) Clinical & Executive Directors Training Regional Clinical Training Free NRT Training / Manual Patches & gum On-site consultation and training Assist Residential Programs with Implementation Trainings Consultation to Residential Programs Distribution of NRT Program Evaluation Study As programs prepared for Licensure, the Tobacco Dependence Program was instrumental in assisting programs to prepare for the tobacco components of the licensure standards. Clinical & Executive Directors Training We sponsored two 3-day trainings for Clinical and Executive Directors to begin to address some of the growing fears as well as strategies for successfully integrating tobacco into the treatment milieu. There are 33 Residential Addiction Treatment Programs in NJ and 29 programs participated in at least one of the trainings. Each program received a comprehensive reference manual (developed specifically for this training), a training manual to provide ongoing training of the staff at each facility, and a resource materials package including videos,, sample patient training materials, a Facilitator�s Guide and Quit Smoking workbook set for patients. Regional Clinical Trainings Additionally, 2 regional trainings were held for over 70 clinical staff of residential programs. NRT The Tobacco Dependence Program was selected by DAS to serve as distributors of NRT, both patch and gum, funded by the state from monies from the MSA. Programs were eligible for free NRT if they were licensed by DAS or applying for licensure. The State chose to fund up to 8 weeks of NRT for up to 80% of all patient/beds in residential treatment. The Tobacco Dependence Program developed distribution procedures for NRT as well as a training manual on the correct use of NRT and protocols for recordkeeping and reporting. The manual was distributed at two trainings conducted for over 60 staff from 31 programs that were eligible for state-funded NRT. On-site Consultation & Training As programs prepared to go tobacco-free, there was an influx of requests for the Tobacco Dependence Program Addictions Consultant and Special Populations Coordinator to assist program �Tobacco Committees�, agency staff, and clinical staff members with policy as well as clinical issues. Our staff partnered closely with treatment providers in preparing to meet the Licensure Standards. Assist Residential Programs with Implementation Trainings Consultation to Residential Programs Distribution of NRT Program Evaluation Study As programs prepared for Licensure, the Tobacco Dependence Program was instrumental in assisting programs to prepare for the tobacco components of the licensure standards. Clinical & Executive Directors Training We sponsored two 3-day trainings for Clinical and Executive Directors to begin to address some of the growing fears as well as strategies for successfully integrating tobacco into the treatment milieu. There are 33 Residential Addiction Treatment Programs in NJ and 29 programs participated in at least one of the trainings. Each program received a comprehensive reference manual (developed specifically for this training), a training manual to provide ongoing training of the staff at each facility, and a resource materials package including videos,, sample patient training materials, a Facilitator�s Guide and Quit Smoking workbook set for patients. Regional Clinical Trainings Additionally, 2 regional trainings were held for over 70 clinical staff of residential programs. NRT The Tobacco Dependence Program was selected by DAS to serve as distributors of NRT, both patch and gum, funded by the state from monies from the MSA. Programs were eligible for free NRT if they were licensed by DAS or applying for licensure. The State chose to fund up to 8 weeks of NRT for up to 80% of all patient/beds in residential treatment. The Tobacco Dependence Program developed distribution procedures for NRT as well as a training manual on the correct use of NRT and protocols for recordkeeping and reporting. The manual was distributed at two trainings conducted for over 60 staff from 31 programs that were eligible for state-funded NRT. On-site Consultation & Training As programs prepared to go tobacco-free, there was an influx of requests for the Tobacco Dependence Program Addictions Consultant and Special Populations Coordinator to assist program �Tobacco Committees�, agency staff, and clinical staff members with policy as well as clinical issues. Our staff partnered closely with treatment providers in preparing to meet the Licensure Standards.

8. The Environment Tobacco products shall not be used in vehicles used to transport patientsat any time.8:42A-3.11 (b) Use of tobacco is prohibited on the groundsof free-standing facilities. (by November 15, 2001) 8:42A-3.11 (a)

9. Policy-Staff & Volunteers Establish policies and procedures addressing time during which former substance abusers (alcohol, nicotine and/or drugs) shall be continuously substance free before being employed. 8:42A-3.5 (b) Staff shall not use alcohol, tobacco or illegal drugs during working hours or when representing the treatment facility. 8:42A-3.5 (b) 1 The minimum period of time during which those persons who had a prior history of substance abuse (alcohol and/or drugs, nicotine) shall be continuously substance free before being accepted as volunteers 8:42A-23.2 (a) 1 ii

10. Treatment Assess the patient�s�tobacco history and interventions, if any.8:42A-9.1 (b) 1 Address each problem identified in the patient assessment within the patient treatment plan.8:42A-9.2 (a) The discharge plan �shall address all unresolved problems�8:42A-18.1 (a) 1

11. Tobacco Education (Have) policies and procedures for making information about alcohol, tobacco and other drug use and abuse available to the public.8:42A-3.6 (b) 8 Provide patients with didactic sessions with respect to tobacco education.8:42A-10.1(c) Provide patients and families with information (about).. self-help and support groups� 8:42A-10.1 (f)

12. FEAR Witch hunt Sobriety issues Too hard Barrier to treatment Policing Loss of revenue

13. The �Grounds� issue Use of tobacco is prohibited on the groundsof free-standing facilities. (by November 15, 2001) 8:42A-3.11 (a) In December 2002, only fifty percent of programs (15/30) had tobacco-free grounds. However, an additional 23% (7/30) had had them previously that year, and had rescinded for various reasons. Despite no longer having tobacco-free grounds, however many continued to treat tobacco and use NRT for clients In December 2002, only fifty percent of programs (15/30) had tobacco-free grounds. However, an additional 23% (7/30) had had them previously that year, and had rescinded for various reasons. Despite no longer having tobacco-free grounds, however many continued to treat tobacco and use NRT for clients

14. Program Evaluation The data used in this evaluation study is derived from three sources: 1.�����Alcohol and Drug Abuse Data System � ADADS Tobacco Items 2.�����NRT Database 3. Executive Directors Survey Did the Licensure Standards produce an increase in the treatment of tobacco dependence in residential addictions treatment in New Jersey? How many agencies had tobacco-free grounds following November 15, 2001, when the tobacco-free grounds provisions became effective? Did the implementation of the Tobacco Provisions of the Licensure Standards (including tobacco-free grounds) result in an increase in premature client discharges? Were clients and agencies receptive to the use of nicotine replacement (NRT) during residential treatment? How much and what types of products were used? Did the Licensure Standards produce an increase in the treatment of tobacco dependence in residential addictions treatment in New Jersey? How many agencies had tobacco-free grounds following November 15, 2001, when the tobacco-free grounds provisions became effective? Did the implementation of the Tobacco Provisions of the Licensure Standards (including tobacco-free grounds) result in an increase in premature client discharges? Were clients and agencies receptive to the use of nicotine replacement (NRT) during residential treatment? How much and what types of products were used?

15. Baseline ADADS Data(n=3472, 10/1/01-12/31/02) 77% smokers (n=2658) Mean age=32 years, 69% male 65% no med coverage Avg 3 previous treatment episodes 65% legal issues 58% reside with child/sibling/parent 26% alcohol - 35% Heroin - 22% cocaine/crack

16. ADADS � special fields 18 c/day 65% quit or cut down 15% disease/symptoms 46% < 5 min; 77% < 30 min 2 quit attempts 53% completed treatment

17. ADADS � special fields at discharge (n=1297) 44% stated policy helped 41% didn�t smoke 22% plan to abstain 13% plan to seek additional help 4.5% left prematurely 31.5% smokers used NRT 24 days = mean length of NRT use There was no increase in irregular discharges. (4.5% policy related) Discharge rates were not statistically different from rates in previous years. The rates of irregular discharge were also not statistically different between smokers and non-smokers. There was no increase in irregular discharges. (4.5% policy related) Discharge rates were not statistically different from rates in previous years. The rates of irregular discharge were also not statistically different between smokers and non-smokers.

19. Director Survey Results 91% participated in survey 87% utilized free NRT 50% tobacco-free grounds 100% smoke-free buildings & vehicles 70% positive effect on clients 60% positive effect on staff 2/3 helped clients reduce or quit Our program conducted a survey with Directors of residential facilities in the Fall of 2002 about current practices and beliefs about tobacco treatment as compared to June 1999 (June 1999 is a random date we chose, it is 6 months prior to the passage of the Licensure Standards). We had a 90% response rate, we used a 60 minute semi-structured interview and in the vast majority of cases met face-to-face with 33 of the 35 treatment directors. The Alcohol and Drug Abuse Data System (ADADS) is a statewide management information system for alcohol and drug abuse treatment agencies operated by the NJ Department of Health and Senior Services, Division of Addiction Services. ADADS collects data on client treatment episodes, I.e., program admission through discharge and DAS maintains the system database. Reporting is mandatory for licensed drug and alcohol treatment providers. The Tobacco Dependence Program in conjunction with the Office of Research and Information, developed a system to collect information relating to the implementation of the licensure standards utilizing additional questions relating to tobacco to be recorded in the Special Fields section of the ADADS form at both admission and discharge. Our program conducted a survey with Directors of residential facilities in the Fall of 2002 about current practices and beliefs about tobacco treatment as compared to June 1999 (June 1999 is a random date we chose, it is 6 months prior to the passage of the Licensure Standards). We had a 90% response rate, we used a 60 minute semi-structured interview and in the vast majority of cases met face-to-face with 33 of the 35 treatment directors. The Alcohol and Drug Abuse Data System (ADADS) is a statewide management information system for alcohol and drug abuse treatment agencies operated by the NJ Department of Health and Senior Services, Division of Addiction Services. ADADS collects data on client treatment episodes, I.e., program admission through discharge and DAS maintains the system database. Reporting is mandatory for licensed drug and alcohol treatment providers. The Tobacco Dependence Program in conjunction with the Office of Research and Information, developed a system to collect information relating to the implementation of the licensure standards utilizing additional questions relating to tobacco to be recorded in the Special Fields section of the ADADS form at both admission and discharge.

20. Survey Results: comments �tobacco as another drug of addiction� Include in all educational programs Utilize NRT Non-enforcement is problematic Utilize services of Tobacco Dependence Program �It�s about time�

21. Survey Results All programs surveyed (n=30; 91% response rate) were providing some tobacco dependence treatment, including assessment and/or individual or group counseling and/or nicotine replacement. Many programs complied with Licensure standards, sent significant staff for tobacco training, utilized on-site expert tobacco treatment consultation, and provided NRT to clients All programs surveyed (n=30; 91% response rate) were providing some tobacco dependence treatment, including assessment and/or individual or group counseling and/or nicotine replacement. Many programs complied with Licensure standards, sent significant staff for tobacco training, utilized on-site expert tobacco treatment consultation, and provided NRT to clients

22. Lessons learned Tobacco treatment can be successfully integrated into addictions treatment Most clients want to address tobacco Treating tobacco did not cause clients to leave treatment early The greatest resistance comes from staff Tobacco-Free grounds were cited as the most challenging aspect of implementation Enforcement of the licensure standards is key NRT was most beneficial in helping treat tobacco Would as much of an increase in tobacco treatment have taken place without the tobacco-free grounds provision? What message do we give clients by allowing continued tobacco use when drug/alcohol use bans are strictly enforced? How successful could the New Jersey policy have been if strictly and consistently enforced? To succeed, such policies need the full support of management. Policies that are too far ahead of the field will be met by resistance. Provision of NRT is a critical part of implementation of a Tobacco-free grounds policy Would as much of an increase in tobacco treatment have taken place without the tobacco-free grounds provision? What message do we give clients by allowing continued tobacco use when drug/alcohol use bans are strictly enforced? How successful could the New Jersey policy have been if strictly and consistently enforced? To succeed, such policies need the full support of management. Policies that are too far ahead of the field will be met by resistance. Provision of NRT is a critical part of implementation of a Tobacco-free grounds policy

23. Reference Williams J, Foulds J, Dwyer M, Order-Connors B, Springer M, Gadde P, Ziedonis DM. The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey. Journal of Substance Abuse Treatment 2005; 28: 331-42. 2658 ADADS forms = # smokers 1,848 of the smokers answered the Special Fields2658 ADADS forms = # smokers 1,848 of the smokers answered the Special Fields

24. Tobacco Dependence ProgramUMDNJ School of Public Health317 George Street, Suite 210New Brunswick, NJ 08901ph: 732-235-8212fax: 732-235-8297www.tobaccoprogram.org