Thinking Holistically – Don’t Forget Tobacco

I am sitting at the annual meeting for the Society for Research in Nicotine and Tobacco in Houston, Texas because I am presenting some of the data we have gathered from an outcome study for our program. This is a huge meeting and I am impressed with the recurrent theme on the clinical tract presentations, which is “although the incidence of tobacco use is up toward 80% in those with mental illness and substance abuse, very few programs treat nicotine dependence.”

This is, in fact, one of the things I believe contributes to our program’s success, the fact that we address tobacco as seriously as and in the same fashion as other drugs. For the patients we treat, 88% use tobacco on a daily basis. We fully integrate tobacco cessation into every aspect of the program. Just as they are expected to be free from drugs, alcohol and addicting medications, we expect them to be tobacco free for the three months they are in treatment. We use nicotine replacement in the form of tapering doses of a nicotine patch for the first six weeks and then they are nicotine free the last six weeks. We strive to include tobacco in every discussion of drugs, alcohol and mental illness because they are so tightly interconnected.

We discuss the literature that indicates tobacco is a gateway drug and can be a relapse factor for alcohol and other drugs. We provide a lot of education and encouragement for the patients to consider not returning to tobacco use when they leave treatment. This takes a lot of work both on the part of the staff as well as the patients. They have to re-wire their brain and thinking in order to be successful in this regard.

For the most part, people do not consider quitting the use of a substance until they have experienced consequences from their use. Most of our patients have experience legal consequences from their drug/alcohol use and are referred by the courts as a condition of their probation/parole/diversion. Often they come from sitting in jail for 2-6 months during which time they have been abstinent from drugs, alcohol and tobacco, however, they have done nothing to change their thinking during that period of time and they invariably begin smoking cigarettes immediately upon release from jail. Some then also relapse to drugs or alcohol in the intervening time between jail and entering the program but others do not because they have learned something from their consequences. Because very few have actually experienced consequences from their tobacco use, they have no desire to change this behavior. Sadly, if one waits for consequences from tobacco use to motivate change, it is usually too late. One study of 20,018 patients with mental illness in Ohio found that observed deaths were three times higher than expected compared to the general population with the mean age of death of 47.7 ± 15.3 years.¹ Heart disease was the leading cause of death and tobacco use in this population played a significant role.

Because no one seems to be able to decide to quit using an addictive substance while they are actively using it, we believe it is up to the treatment facility to provide a safe, drug free/tobacco free environment where patients can have the opportunity to experience freedom from tobacco, giving their brain a chance to heal and at the same time learn new thinking and behaviors. There is a significant body of research demonstrating that nicotine has a profound negative effect, similar to alcohol and other drugs, on the learning and memory part of the brain. Chronic nicotine use can result in decreased neurogenesis and shrinkage of the hippocampus, contributing to difficulty in new memory and learning. It makes sense that if someone continues to smoke a pack per day while they are attempting to participate in treatment for alcohol, drug abuse or mental illness, they may have difficulty learning and retaining what they are being taught in treatment. Our patients have failed an average of three previous inpatient treatment programs and one intensive outpatient program and they admit to having used tobacco throughout those programs, often increasing their use or some even beginning to use tobacco for the first time in treatment – because everyone else is using tobacco. Because addiction can be thought of as a “disease” of the learning and memory part of the brain, repeated use of the substance causes the behavior to become “hard wired” and the slightest trigger or reminder of why it was used triggers the use. On the positive side, there is evidence that removal of the drug allows the brain a chance to heal, with regeneration of the hippocampus and improved ability to learn and retain new information. In fact there is some evidence that it takes three months for a stem cell in the hippocampus to grow and differentiate. To me this means that Alcoholics Anonymous has known this intuitively forever – they say that if you want to quit drinking, they recommend you don’t drink for 90 days (and attend a meeting daily to ensure you don’t drink that day) and you begin to “get it”. So in this sense, recovery requires two parts – the first is to free the brain from the addictive substance and the second is to re-wire new thinking/behavior on how to handle all the reasons the substance was used in the first place.

In our experience, the number one reason people continue to use addictive substances is because this has become their coping mechanism for dealing with stress, trauma, anxiety, anger, pain, fear or any other emotion that drives the human condition. Sadly, tobacco use has been so “normalized” by treatment providers it is usually ignored or forgotten and it is not recognized as playing an integral role in the development or exacerbation of symptoms of mental illness. Because of cross tolerance, the brain basically sees all addictive drugs the same and will be happy to use them interchangeably if the “preferred” one isn’t available at the moment. In order to optimize treatment we believe that it is most helpful to deal with all the maladaptive coping mechanisms at the same time and to teach new adaptive coping mechanisms in an environment where people are best able to learn them.

We begin patients in their first month by encouraging their participation in the National Acupuncture Detoxification Association 5-point ear acupuncture protocol that we offer four days a week as a group relaxation therapy. Consistent with the literature, we find that tobacco use can be a contributing factor to treatment drop out. This was true, in our experience, even more so in the years before we went tobacco free. However, we have found that the more patients are willing to use the ear acupuncture, the more likely they are to remain and participate in treatment, even if they plan to resume tobacco use as soon as they are able. Most patients find this profoundly relaxing and report it aids them with sleep, and focus and concentration. Consequently the patients with symptoms of PTSD and ADHD are the ones most likely to use this as often as possible.

The acupuncture is something that staff can do for patients but we begin to teach them things they can start doing for themselves to manage their affect or whatever emotion they use drugs, alcohol or tobacco for. We introduce all patients to Heartmath®, a biofeedback technique based on heart rate variability and help them learn how to use this and practice it on a regular basis. We offer the patients the opportunity to learn and use tapping or pressure on acupressure points throughout their body to self-soothe. Most of the staff is trained in what we call “Brain Synchronization Therapy” (BST), a softer and gentler form of Eye Movement Desensitization Reprocessing (EMDR) and they use numerous “energy therapies” with this to help patients balance their right and left brain hemispheres – integrating their emotional response to past traumas with their thinking about it so it can be digested and they can move on. We offer recreational therapy on most days of the week and encourage exercise as the best therapy to promote neurogenesis in the hippocampus and improve depression and anxiety. We have an awesome gym with track, ball courts, weight room, swimming pool and even a bowling alley where patients can go daily and work out. We offer Tai Chi and Yoga as complementary treatments for pain management and emotional regulation. All these, together with the time away from the drugs, alcohol and tobacco, allow the brain to heal, promote relaxation and stress management and allow patients to realize that they actually do have control over their autonomic nervous system.

The other piece that is equally necessary is the incorporation of new memory and learning and the re-wiring of new thoughts and behaviors. We incorporate two cognitive/behavioral treatments in the program. One is Strategies for Self-Improvement and Change (SSIC) that was originated for the criminal justice system and we have modified to use with those with mental illness. The other is Dialectical Behavioral Therapy (DBT) where we introduce patients to mindfulness as a skill for affect regulation. Once the patients have been in the program for a month they begin to participate in cue-exposure therapy that is done as a group once a week. This is a therapy that has mixed results in the literature but we believe the reason for this is most studies of cue exposure for substance abuse have not controlled for the use of tobacco. In this group, patients are expected to imagine a scenario where they would be triggered to relapse. The therapist guides them through the process in which they are suppose to allow their cravings to intensify but they are instructed not to use in their imagination. It is very clear when patients are actively participating as they have visible signs of discomfort – they feel sick to their stomach, are sweating, etc. After allowing their cravings to intensify for a period of time they are then asked to use refusal skills to get out of the scenario in their mind. When done appropriately this can then wire new information into the brain. The new message is one can have a craving and not give into it, thereby not reinforcing the craving, which can ultimately lead to decrease in cravings. However, if someone left that group and had a cigarette – they would be negating anything they accomplished in the group and would actually have reinforced the craving. We believe this is a very powerful tool that should never be used in programs where tobacco use is allowed. We even discovered that we had to move this group to after lunch because some patients were leaving the group and binging on food which would also reinforce the craving since the behavior and motivation behind it is the same (using something outside my self to change the way I feel).

Not paying attention to tobacco use also tends to get patients put on more or higher doses of psychiatric medications. Since most inpatient facilities are now smoke free, people in locked wards are unable to smoke and can experience significant nicotine withdrawal. Symptoms of major depression and nicotine withdrawal are virtually identical. When patients are allowed to smoke intermittently, as in most substance abuse treatment programs, then the withdrawal is prolonged and intensified and they tend to be miserable. Rather than learning new things they tend to be focused primarily on when they can have their next cigarette, and they invariably get put on an antidepressant medication to “help them cope”. Our patients begin to notice after a month not smoking that they actually feel better and for those not on medications, we don’t have to start any and for the others already on meds we are able to begin to decrease their medications. Many of the antipsychotic medications are metabolized by the same liver P450 enzyme system as tobacco smoke constituents. Patients learn if they smoke more, this decreases the sedating side effects of the medications, however they also don’t work as well for psychosis. When such people are inpatient where they can’t smoke, the side effects worsen and the patients can become extremely sedated. Often new medications are given to these patients to combat the side effects where it would make more sense to lower the dose of the medications.

Getting people to rethink their tobacco use is a significant paradigm shift and takes a lot of work but we are seeing that it is beginning to pay off in the long run. We have been engaged in an outcome study since 2009, following patients for a year after treatment in this three-month program to see how they do. By December 2011 we had 105 people complete the year follow-up. 53% were sober and doing well at the end of the year and 30% were continually abstinent from drugs and alcohol the entire year. While 88% were using tobacco daily at the time of admission, only 75% were using tobacco at the end of the year. We had convinced some people to continue to remain tobacco free after discharge and these were the people most likely to be continuously abstinent at the end of the year (p=.03). The majority of those who were sober and doing well had significantly decreased their tobacco use and were continually attempting to quit again. Many voiced the wish that they had stayed quit because it was so easy to quit in the program and it isn’t very easy out in the real world. Relapse to drugs or alcohol was highly correlated with tobacco use (p=.012). We had only 19% recidivism – meaning these people had relapsed and were incarcerated for new charges. These outcomes are very good for a population that is historically very difficult to treat. We are convinced that addressing tobacco the way we do plays a big role in this.

 We believe that any program that is residential or inpatient should provide a tobacco free environment as part of their program in order to provide optimum treatment. Many of the well-known programs, still allow patients to use tobacco while in treatment, using the rationale that they are afraid people will not come to their program if they can’t smoke. It is concerning that a program would put their financial bottom line ahead of what is best for the patient. Especially in light of the fact already demonstrated in the literature that tobacco use is associated with treatment drop out and the concern that ongoing tobacco use may limit their ability to learn anything new from treatment.

1. Miller, Paschal, and Svendsen. Psych Services 2006;57:1482-1487.