I. Treatment and Prevention

In accordance with the avowed purposes of NAADAC, The Association for Addiction Professionals—prompting and supporting the most appropriate and highest quality of care and treatment for chemically dependent clients/patients and their families—advocates and supports the development of policies and programs that promote the prevention and treatment of nicotine dependence on a par with alcoholism and drug dependence.

NAADAC understands that some cultures, such as First Nations People, use tobacco as a medicine in ceremonial practice. For that purpose, to honor and include cultural traditions and healing practices, NAADAC recognizes the difference between tobacco abuse and dependence and ceremonial tobacco use.

NAADAC recognizes the need for the addiction treatment community to adopt a consistent position on issues related to tobacco use and nicotine dependence, noting that nicotine addiction is especially prevalent among those who suffer from alcoholism and other drug dependencies1. Indeed, the relationship is so strong that intractable heavy smoking is a predictor of unrecognized alcohol abuse2. Tragically, tobacco-related diseases are the leading cause of death in patients previously treated for alcoholism and/or other non-nicotine drugs of dependence3. Nicotine dependence treatment is imperative in such high-risk patients4.

NAADAC recognizes that nicotine is a psychoactive drug and that its regular use can result in nicotine dependence and premature death5. It is estimated that 2.5 million people die worldwide each year because of tobacco use and that by 2020 the death toll will be at least 10 million if present trends in tobacco consumption continue6. In the United States, cigarettes kill 430,000 people directly each year7, and environmental tobacco smoke kills more than 53,0008.

The preponderance of data from USDHHS, WHO, the Surgeon General, the Environmental Protection Agency, CDC, the American Heart Association, the American Cancer Society, and the American Lung Association demonstrates that tobacco use (including smokeless tobacco) and exposure to environmental tobacco smoke (a class A carcinogen) are major contributors to illness, disability, and death. Cigarettes kill many more people than all other drugs and alcohol combined9. In fact, smoking kills more Americans each year than alcohol, cocaine, crack, heroin, homicide, suicide, fires, car accidents, and AIDS combined.

NAADAC regards nicotine addiction as a primary health problem, and recognizes tobacco-caused illnesses as the direct consequence of nicotine dependence. Just as alcoholism and other drug addictions have not always been viewed as primary diseases, the health profession has traditionally viewed tobacco use as a risk factor for other diseases, but not as a primary health problem itself. This approach has impeded rather than advanced the development of optimal treatment methods for clients addicted to nicotine.

NAADAC recommends that all patients presenting for substance abuse services be screened and assessed for tobacco use and, where applicable, that a tobacco or nicotine diagnosis, using DSM-IV or ICD 9 criteria, be made in the patient's chart.

NAADAC further recommends that tobacco dependence be included in the treatment plan for every patient to whom it applies. Furthermore, discharge plans should address all unresolved problems, including the use of tobacco, identified at admission or during treatment.

NAADAC recommends that information about the desirability of participating in self-help support groups such as Nicotine Anonymous (NicA) be made available to patients and family members.

NAADAC strongly supports and encourages the provision of tobacco education within the addictions treatment milieu. At a minimum, tobacco specific didactic sessions can be added to the existing alcohol and other drug, HIV/AIDS education, and health curriculum. More appropriately, in integrating tobacco treatment on a par with alcohol and other drug dependence treatment, nicotine dependence material can be incorporated into essentially every general education topic, i.e., use of chemicals to modify and control feelings, consequences of chemical use, etc.10

NAADAC further encourages addictions professionals to include tobacco education for family members of clients, as this will put them in a better position to support and encourage recovery from tobacco dependence for the patient. Family members who receive tobacco education also gain the opportunity to examine their own experiences with tobacco, which may encourage tobacco users to seek assistance in quitting and non-users to gain validation and support in setting healthy and appropriate limits regarding exposing themselves to environmental tobacco smoke pollution.

NAADAC acknowledges that addiction counselors need to demonstrate healthy lifestyles through role modeling. As our field moves towards treating tobacco dependence, we recommend that staff not be identifiable as tobacco users during working hours or when representing the treatment facility.

NAADAC acknowledges the change in recognition of tobacco as a drug of addiction and the conflict this may create for members in the role of addiction professional. Therefore, NAADAC encourages each state affiliate to develop assistance services for members who wish to address their tobacco use issues.

NAADAC strongly encourages that treatment facilities and the surrounding property be designated tobacco-free areas. NAADAC supports the prohibition of the use of tobacco products and spit tobacco within all buildings and on the grounds of all free-standing treatment facilities as well as in vehicles used to transport patients at any time.

NAADAC recommends that public and private sector treatment providers and employers offer tobacco-specific training as part of their general in-service training programs to all employees to explain the rationale for treating nicotine dependence within the addictions milieu.

NAADAC supports the emphasis on training of health care professionals, including addictions specialists, to regard tobacco dependence as a health issue that requires parity of treatment with alcohol and other drugs of dependence. NAADAC pledges to provide opportunities for training in tobacco dependence and to further suggest scientifically-based resources where addictions specialists might procure this training.

NAADAC supports making information about tobacco use and abuse available to the public. NAADAC encourages early teaching in the family and in schools about the risks associated with tobacco, including smokeless tobacco (SLT) and environmental tobacco smoke (ETS). NAADAC recommends prevention programs to educate members of the public about the dangers of tobacco use during pregnancy and lactation, and the effect of environmental tobacco smoke (ETS) on children.

II. Policy and Legal/Regulatory Issues

NAADAC supports the promotion of research into the causes, prevention, and treatment of nicotine addiction, including the natural history of tobacco dependence and the clinical management of nicotine replacement.

NAADAC endorses assigning the regulation of all nicotine-containing products intended for human consumption to the Food and Drug Administration and supports the regulation of cigarettes, smokeless tobacco and all nicotine-containing products as nicotine-delivery devices.

NAADAC advocates the strengthening of warning labels on tobacco products. NAADAC further advocates that warning labels be written in simple language and state the harm ETS causes others, the diseases caused by tobacco use, and the risk of addiction. In addition, NAADAC would like to see the warning labels placed more prominently and on a larger percentage of the package face of tobacco products.

NAADAC advocates the establishment of smoke-free policies in all health care facilities and in locations selected for workshops, clinics, seminars, and conferences that address health care issues and chemical dependency. NAADAC pledges that association-sponsored functions, meetings, seminars, and workshops will be smoke-free.

NAADAC encourages third-party reimbursement for the treatment of tobacco dependence by qualified health professionals who use clinically recognized methods.

NAADAC urges all institutions involved in health care, including addiction treatment facilities, to divest any tobacco industry holdings, since profits of this industry are in direct opposition to controlling the spread of this epidemic in children and adults.

NAADAC supports laws that limit access of tobacco products to minors and that make it illegal to give, sell, or provide tobacco products to minors.

Footnotes

1 Hurt, Eberman, Slade, and Karan, 1993

2 Hurt et al., 1994, pp. 867-872

3 Hurt et al., 1994, p. 1102

4 Hurt et al., 1994, p. 1097

5 U.S. Department of Health and Human Services (USDHSS], 1988; World Health Organization [WHO], 1995

6 Peto, Lopez, Boreham, Thun, and Heath, 1992

7 Centers for Disease Control and Prevention [CDC], 1993

8 Glantz and Parmley, 1991; USDHHS, 1986

9 Lynch and Bonnie, 1994

10 Rustin, 1998

References

Centers for Disease Control and Prevention (1993). Cigarette smoking: Attributable mortality and years of potential life lost-US, 1990. Morbidity and Mortality Weekly Report,42:33, 645-649.

Glantz, S.A., & Parmley, W.W. (1991). Passive smoking and heart disease: Epidemiology, physiology, and biochemistry. Circulation, 83:1-12.

Hurt, R.D., Offord, K.P., Croghan, I.T., Offord, K.P., Davis, L.J., Morse, R.M., Palomino, M.A., & Bruce, B.K. (1994). Nicotine dependency treatment during inpatient treatment for other addictions: A prospective clinical trial. Alcoholism: Clinical and Experimental Research, 18:4, 867-872.

Hurt, R.S., Eberman, K.M., Slade, J., & Karan, L. (1993). Treating nicotine dependence in patients with other addictive disorders. In C.T. Orleans & J. Slade (Eds.), Nicotine addiction: Principles and management. New York: Oxford University Press.

Lynch, B.S., & Bonnie, R.J. (Eds.) (1994). Growing up tobacco free: Preventing nicotine addiction in children and youths (p. 4). Washington, DC: National Academy Press.

Peto, R., Lopez, A.D., Boreham, J., Thun, M., & Heath, C. (1992) Mortality from tobacco in developed countries: Indirect estimation from national vital statistics. Lancet 339:1268-1278.

Rustin, T.A. (1998). Incorporating nicotine dependence treatment into addiction treatment, Journal of Addictive Diseases,17:1, 83-108.

U.S. Department of Health and Human Services (1986). The health consequences of involuntary smoking. DHHS Publication 87-8398. Washington, DC: Government Printing Office.

U.S. Department of Health and Human Services (1988). The health consequences of smoking: Nicotine addiction. DHHS Publication 88-8406. Washington, DC: Government Printing Office.

World Health Organization (1995). Guidelines for controlling and monitoring the tobacco epidemic.