Tobacco Recovery in the Addiction Recovery Space: Time for Action!

“For decades, people in recovery from addictions to other drugs have their lives cut short by tobacco-related diseases. Their drear friends, patients, and colleagues died from nicotine addiction, but it could also be said they died from blindness – the failure to see nicotine as an addictive drug and the failure to see smoking cessation within the rubric of addiction recovery” – William White 2011

Tobacco addiction has ravaged our society for well over one hundred years, and it has decimated the addiction recovery community. People who use other drugs and those of us in recovery use tobacco disproportionally with rates of use roughly three to four times higher than the general public. Tobacco related illness remains the leading cause of preventable death in the United States and the leading cause of death from all causes in the addiction recovery community. It is a disgrace to our field that we have failed to meaningfully address it in any systematic way within the addiction treatment and recovery support care system that has evolved over the last 55 years. To have a healthy America, we must more effectively address this critical issue. It is killing our loved ones who are needlessly dying decades before they should. It is time for the addiction treatment and recovery support services to focus in tobacco recovery.

When I got into recovery 38 years ago, nearly all mutual aid spaces were tobacco use infused. In therapy sessions, the counselors and the clients smoked so heavily it was difficult to see the people on the other side of the circle. Tobacco in that generation was ubiquitous, in that same tobacco laden breath, the leaders who helped set up all those structures nearly to a person suffered from or died from tobacco related illnesses. Bill Wilson, Jimmy Kinnon, Marty Mann and Harold Hughes among many others. While it is less visible now in our treatment and recovery support spaces, it remains in the shadows, the thing we do not talk about, or address and the silence is killing us. We must change this.

Tobacco use and mortality in the context of other substance use conditions:

• Tobacco is the leading cause of substance use illness and mortality – annual total deaths are around 480,000 or one in five US deaths. (Report of the Surgeon General, 2014).
• People seeking addiction treatment use tobacco at much higher rates than the general public (Addiction, 2014).
• Tobacco is the leading cause of death in the SUD recovery community (JAMA, 1996) (Journal of Substance Abuse Treatment, 2020).

• Addressing tobacco use in addiction treatment is associated with more effective outcomes – with long term recovery rates up to 25% higher (ASAM).
• Our current service and support systems have been reticent to address tobacco use even when the persons served have been open to exploring their tobacco use (Addiction, 2014). (Journal of Substance Abuse Treatment, 2020). 

Tobacco use rapidly normalized globally

As White wrote about in Early American Alcohol and Tobacco Use (2014), tobacco was viewed as medicinal by Native Americans as well as colonists after its introduction to the Americas in the early 16^th century. Tobacco use was normalized worldwide at a rapid rate through the 16^th and 17th centuries and became a main source of revenue here in the United States. The harms started to become apparent. By the late 18th and early 19th centuries there was a movement against tobacco use that was gaining momentum that was joined by prominent physician, signer of the Decleration of Independence Dr Benjamin Rush. Rush published an essay, Observations Upon the Influence of Tobacco Upon Health, Morals and Property in 1798.

The mass production of cigarettes was revolutionized by the invention of automated cigarette-making machines like the Bonsack rolling machine in 1880. Cigarettes as a convenient and inexpensive nicotine delivery system expanded the use of tobacco broadly across the United States and beyond. It was key to the rise of Big Tobacco. In the early 20^th century it was marketed as a health aid to reduce anxiety and to help people stay slim. By the 1960s, the data showing that tobacco use was associated with cancer and a host of life-threatening illnesses became increasingly hard to ignore and the use of tobacco began to decline across most of society, but not in the addiction recovery community.

Refining nicotine delivery systems to maximize addiction

It is no accident that the prevalence of tobacco use increased when a more convenient delivery system was introduced in the form of machine rolling of cigarettes and efforts to perfect getting nicotine into the brain continues. A dive into cigarette technology clearly shows efforts to increase the addictive nature of the product over time. This is no surprise to those who understand the evolution of addictive drugs. Consider coca leaves which are relatively mild in respect to stimulant properties and how the development of powder cocaine increased the potency of the drug and increased its addictive properties. Crack cocaine delivers the drug even more rapidly across the blood brain barrier and therefore increases the addictive properties of the drug. The same dynamics occur in respect to nicotine delivery systems over time with the same goal, get more drug into the brain more quickly for longer durations of time.

Vaping is a highly efficient method of delivering nicotine to the brain. Vape cartridges contain up to three cigarette cartons worth of nicotine. It is also often the case that people who initiate vaping also initiate or maintain the use of cigarettes, so people use both delivery systems which increases the amount of nicotine in their bodies. The result is higher concentrations of nicotine over longer periods of time. For sellers of these addictive products, this is exactly what they want as people are hooked to their products more severely. They make more money.    

People In recovery are a key target market for Big Tobacco

As noted above, tobacco use has been endemic in the recovery community. As concerns about tobacco use increased in the 1950s and beyond, tobacco companies deployed research teams to show benefits of tobacco use in respect to mental illness including substance use disorders. These companies actively marketed to marginalized communities, including people in recovery from other addictions. One notable campaign was “Project SCUM” (Sub-Culture Urban Marketing) that targeted “consumer subcultures” in the San Francico area, specifically to gay people in the Castro district, “rebellious, generation X-ers”, people of “International influence” and “street people.” As evidenced by the name of their marketing and media campaign, they did not think very highly of their own customers but instead had open contempt for them.

We continue to have a culture of tobacco use in our addiction recovery communities even as it is killing off our own community members. Our friends, our neighbors and far too often ourselves. We have embraced their manipulative messaging around tobacco being more socially acceptable for us we have overcome other addictions and “deserve” to keep this one. We perpetuate the myth that addressing tobacco use should not occur concurrently with other substances. We bought their lies that a focus on tobacco recovery risks full resumption of use. We bought into their media campaigns, hook line and sinker, even with their thinly veiled contempt for us. We suffer and die, they make money. It is well beyond the time to change the culture of normalizing tobacco use in our communities of recovery.

Progress is being made but we have a long way to go

Tobacco use is prevalent in the addiction service system workforce and interventional strategies should address tobacco recovery systematically in treatment, peer support services and within the addiction recovery community. One of the things I am quite proud of is that we are making progress here in Pennsylvania. A few years back, people from our State Tobacco Free Recovery Initiative (STFRI), which is supported by the Pennsylvania Department of Health through a grant from the Centers for Disease Control and Prevention began to address tobacco recovery across our state. An area of focus has been on normalizing tobacco recovery across our space. In the community, in the service provider space and with all persons served. We have been partnering with them over the last few years towards this goal. Through these efforts, we have supported dialogue within the community, disseminated information on tobacco recovery training and supported collaborative efforts wherever possible, because the work they are doing is to support wellness in our community. I was even directly involved with a significant theme of their campaign, Tobacco Recovery Is Recovery, Let’s Talk About It.

Two years ago, a colleague Brian Coon, Director of Clinical Program Services at Pavillon in Mill Spring, N.C  wrote about how they went tobacco free years ago in their program. While the culture in treatment has been to ignore tobacco use, they addressed it head on and as part of their comprehensive and individualized care process. They normalized a focus on tobacco with their staff and clients. They incorporated nicotine use across their entire assessment, treatment and multidisciplinary team approach. This meant that medical, psychology, nursing, spiritual care and counseling staff all applied their efforts for each patient on an individualized basis. It took a long time; they addressed organizational barriers and what they have learned in respect to sustaining that change through ongoing training and focus within their leadership team. It is working. If it works there, of course it can work in other places. For the naysayers who will inevitably assert that it may be true but now is not a good time to do so, the stark truth is that over the last 50 years we have not managed to find the right time to normalize tobacco treatment and recovery support systemically. There will never be an optimum time, so right now is the perfect moment to focus on this critical issue.    

Steps to a future in which tobacco recovery is normalized in our other addiction recovery communities.

1. Reinforcing messaging that tobacco recovery is a primary area of addiction service focus and not an ancillary matter.
2. Educate treatment providers, recovery support service providers and all other relevant community groups about expanding opportunities for tobacco recovery for all staff and persons served in all our communities.
3. Ensure that every person is provided with information and resources to support tobacco recovery in every one of our doors that they walk through.
4. Making tobacco recovery visible in all our other addiction recovery communities.
5. Supporting all pathways to tobacco recovery for everyone who works in and is served within all care settings.

In Closing:

In 2011 in the quote leading this that the legion of those we have lost in our communities from tobacco related illness died from a form of systemic blindness in regard to the tragedies that unfolded one loss at a time. We can be blind no longer, we must normalize tobacco recovery now, for the sake of ourselves and the next generation.

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