Chapter 4:

Chapter 4:
The Nicotine-Dependent
Staff Member
A Show of Hands: Our Lives Have Been
Nicotine Dependence: A staff Issue
Staff Recovery
The For Smokers Only Workshop
Employment Concerns
The Nicotine-Dependent
Staff Member

A Show of Hands: Our Lives Are Touched

In 1995, the Addressing Tobacco… project learned of the death of a colleague and
supporter of the project. This man, a counselor at an addictions treatment program in
New Jersey, had attended our first annual conference. At that program in New Jersey, had
attended our first annual conference. At that time, he saw the inconsistency of his
continued use of tobacco while holding a role-model position in an addictions treatment
program. In the following months, he was able to stop his own use of tobacco. He
gratefully acknowledged the help he had received from our project and began to
implement changes in his agency’s approach to nicotine dependence. We were very
saddened to learn of his death from a tobacco related disease.
May anger become determination
May hope transform loss
May tears fuel our commitment
May sharing lift our spirits
May families heal and find comfort
May knowledge teach us patience
May love be our motivation
May compassion guide our work
We looked for a way to acknowledge his loss among with the others so many of us in the field of chemical dependency treatment have experienced, due to tobacco-caused illness. We have lost colleagues, patients, parents, grandparents, siblings, spouses, and dear friends. We wanted to demonstrate that there were names and stories behind the statistics we use when we talk about tobacco-caused illness. We can no longer speak. With pens we left our thoughts, our feelings, our voices, and our commitment to do something to help stop the tobacco epidemic and to reach out to those who struggle to recover from nicotine dependence (Figure 4-1) This first banner was signed by participants of the Address Tobacco… project’s 4th
Annual Conference (Figure 4-2). Since then, banners have been created around the
country by school children, members of civic organizations, veterans, college students,
patients in addiction treatment programs, and other whose lives have been touched by
tobacco. One or another of these banners has been signed by President Bill Clinton, Vice
President Al Gore, former Surgeon General C. Everett Koop, former NJ Governor Jim
Florio, and the late Victor Crawford, a tobacco lobbyist who went on to become a
powerful advocate for tobacco control (Appendix O & C-1).
Nicotine Dependence: A Staff Issue
Tobacco use and nicotine dependence are intricately woven into the history of chemical dependency treatment and recovery. From the founders of AA who died as a result of tobacco-caused illness, to the utilization of smokeeaters in staff and patient lounges, to the exclusion of addiction and MICA units from smoke-free policies in hospitals, to the extremely high percentage of smokers among patients presenting for addiction treatment, alcohol and nicotine have been closely linked. It is not surprising, therefore, that staff use of tobacco is only just beginning to be addressed as a key issue. As the treatment field comes to understand the profound impact tobacco has on the client community, staff use of tobacco comes more clearly into focus (Appendix P). As this happens, staff discomfort becomes more acute, and staff and patients alike question what is meant when we talk about someone having a full recovery. As more and more knowledge about nicotine is publicly disseminated, it becomes increasingly difficult to ignore the incongruent message of tobacco use by staff. The issues is further clouded when staff members use tobacco in the company of patients, blurring the boundary lines between the counselor and clients. Counselors step out of their role as facilitators of recovery and, actually, become facilitators of continued substance use. This incongruence is evident as the counselor verbalizes to the patient a need to change from a drug-affected lifestyle, yet engages in the use of a dangerous drug with the client. In the late 1980’s, an addictions treatment program in Western Pennsylvania tried to go tobacco-free. Staff sabotaged the effort and the policy was rescinded. About six months later, the secretary to the director wrote her boss a note of apology. In the note, she explained that, until recently, she had been actively addicted to nicotine. She apologized for being one of those how had undermined the policy. She explained that at the time, she had felt that she was so addicted to nicotine that she would not be able to continue working there if she could not smoke. Figure 4-3 When clients and staff use separate smoking sections, or staff use out of sight of clients, there is an implied understanding that the use of tobacco is not acceptable. The lingering smell of tobacco on the staff member’s clothes, hair, or breath causes the primary message of hope—that life in recovery can be lived without the use of dependency-
producing substances-to be questioned. In addition, staff members who continue to use
tobacco products may find it difficult to support a tobacco-free policy (Figure 4-3). Some
of the resistance to change comes not only from the high prevalence of nicotine addiction
among treatment professionals themselves, but from the mixed feelings staff have about
treating nicotine dependence.
Staff Recovery
Providing recovery assistance to staff who use tobacco will help the program make the
transition to tobacco-free status, as well as help the staff members attain better health.
Nicotine treatment options can be offered to all levels of staff at each treatment site, for
each shift, whether or not their job brings them into direct contact with clients. It may
appear that only clinical staff need to address their tobacco use, but support staff,
administrators, housekeeping personnel, dietary, van drivers, volunteers, evening and
night shift staff, and grounds people also should be offered assistance to stop smoking.
Different types of treatment can be offered to staff members on an on-going, permanent
basis. This allows individuals the opportunity to select the option which suits their
individual needs. Any staff member who continues to use tobacco products and is not
offered assistance as the program shifts to become tobacco-free is a potential stumbling
block for the successful implementation of the tobacco-free policy.
Many resources are available to assist the person who wants to quit smoking. These include materials and programs from the American Cancer Society, the American Lung Association and Nicotine Anonymous, a 12-step self-help program based on the principles of Alcoholics Anonymous. Smoking cessation programs may be offered through hospitals, and some therapists who specialize in addictions counseling will treat nicotine dependence. In addition, there are inpatient programs and retreats offered for those who feel this better suits their needs (Appendix L). Print materials, ranging from daily meditation books to self-help workbooks, are available at bookstores or distributed through sources such as Hazelden Educational Materials and the National Cancer Institute (Appendix C). Pharmacological adjuncts such as the nicotine patch and nicotine gum, once only available by prescription, are now over-the-counter items in pharmacies. Starter kits come with information and often a connection to a telephone counseling service. Other pharmacological adjuncts are available by prescription and include nicotine nasal spray, the nicotine inhaler, and bupropion (Zyban) which is an antidepressant which has specifically been shown to be effective in the treatment of nicotine dependence. A sound, behavioral treatment program combined with adjunctive medication is an effective combination, and support in the form of self-help groups provides additional, useful assistance. As with recovery from other drugs, relapse is common, but repeated quit attempts often lead to success as the individual learns what it takes to become smoke-free. By offering staff a variety of options to stop, each staff person can design a program that is suited to meet his or her particular needs and situation. The For Smokers Only Workshop
The Addressing Tobacco… project has developed a 5-hour motivational workshop to help
nicotine-dependent staff members examine their tobacco use and tobacco use history
(Appendix Q through Q-10). This workshop, called For Smokers Only (FSO), is usually
held on-site at a treatment facility during work hours. It is a voluntary program available
for all levels of staff. The workshop is designed to help staff members assess the place of
tobacco and nicotine in their lives with the goal of moving towards stopping use.
Through use of the Stages of Readiness for Change Model developed by Prochaska &
DiClemente (Chapter 6), staff members can determine what actions they can take to
move towards becoming abstinent.
Assessing Use
Staff members participate in various exercises to assess use of tobacco & nicotine
including the Carbon Monoxide Monitor, the Fagerstorm Test, and the smoker Partner
Interview.
 The Carbon Monoxide (CO) Monitor measures the level of this substance in the lungs. Levels are indicated on a monitor screen and information is given as to health risks at each level.  The Fagerstorm Test poses questions relative to number and frequency of cigarettes smoked as well as circumstances surrounding smoking behavior (Appendix G).  The Smoker Partner Interview reveals a history of the individual’s tobacco use. Participants introduce their partner to the group using this information. The workshop facilitator then leads the group in looking for commonalties among the histories, and similarities among the reported patterns of use, progression of addiction and previous quit attempts (Appendix Q-4). Information from these three sources is recorded by each participant on the Assessment Form (Appendix Q-5).
Personal & Professional Concerns
During an FSO workshop, staff members share their personal and professional concerns.
Many report feeling like a fraud, a hypocrite and a failure, and express a range of
emotions including shame around their continued tobacco use. Staff members often
realize that tobacco use compromises their position as a role model and a professional.
One counselor reported that she feels “like a junkie in a crack house” when she takes her
smoke breath in the corner of the courtyard at her treatment facility. While this conflict is
painful, it an also be a motivation toward stopping. These concerns about tobacco use are
recorded on the Assessment Form.
Barriers & Facilitators
Through education and group discussion, attendees at an FSO workshop examine how
intricately nicotine use has become woven into their lives. Participants look at their
personal barriers and facilitators to stopping use, recording them on their assessment form as the group facilitator lists them on the board. As a group, they work on reframing these barriers so that they can become facilitators (Figure 4-4). This process begins to address the complex clues that have come to signal smoking. Moving from Barriers to Facilitators
“My job is putting pressure on me to stop smoking.” For many people, the feeling of pressure and tension is often a trigger to use. Others report feeling a need to react or retaliate to being told what to do. This can be reframed to become, “I can use this opportunity to really force myself to look at my smoking. It’s been something that I keep putting off doing. Now that I won’t be able to show evidence during work hours, I might as well look at stopping.” “My clients confront me about smelling of smoke and ask all kinds of personal questions about my smoking. Yesterday, one of them actually sniffed me. I tell them, ‘We’re here to work on you, not me. I’m the counselor, you’re the patient.” The changing climate around nicotine in addictions treatment leaves staff members who use tobacco feeling caught between a rock and a hard place. Some staff members may feel shame and guilt, while others exhibit righteous indignation. At the very least, many feel uncomfortable. The boundary line between who is the addicted client and who is the counselor becomes blurred. This conflict can be reframed to become, “My use of tobacco makes me feel compromised in my position as a role model and professional. I have always taken pride in the role I plan in the lives of my clients. It really is time for me to make some positive changes in my life. I challenge my clients everyday to get honest with themselves. I think it’s time I challenge myself about my use of tobacco.” “The only break I can get in this place is when I leave the building and go outside to smoke.” As counselors, we teach our clients to take care of themselves, find balance in their lives, and live by the slogan, “Easy Does It.” We need to do the same for ourselves in the workplace. Our breaks are very important. They give us a few moments to center and renew ourselves so we can perform at our best. This problem can be reframed to become, “I can still take care of myself and take my breaks at work without having to run outside to smoke. I am able to set boundaries at work. I can clearly establish that I am not to be disturbed during my break time. I can use my break time to read literature that supports my not smoking, to medicate quietly, or to spend time in prayer.” “My children are always telling me to stop smoking. I will not have my child tell me what I should or shouldn’t do. I’m the parent.” For some people, the idea that a child is telling the parent how they should behave provokes a sense that children are being insubordinate. This can be reframed to become, “I realize my children are scared because they know the dangers of smoking. I want to be around for my children and be an appropriate role model for them. I can work on stopping smoking for me and for them.” Figure 4-4 The Public Health Model
A discussion of the public health model (Chapter 1) answers questions regarding
the importance of tobacco & nicotine issues. Using the section on the public health
model from the slide show training kit, Kicking Out Mr. Butts (Appendix C-l) an
overview of the scope of the problem is presented along with the rationale for
addressing nicotine dependence in the chemical dependency paradigm.

Nicotine, an Addicting Drug
The pharmacological and behavioral aspects of nicotine dependence and the similarities
between this drug and other drugs of addiction are also presented using
slides from Kicking Out Mr. Butts. The use of pharmacological adjuncts to assist
with stopping smoking are also reviewed. Participants learn the value and limitations
of the gum, patch, nasal spray, inhaler and bupropion. (For more information,
see Chapter 6). On the Assessment Form, participants personalize the information
to their particular situation.

Appling the Stages of Readiness for Change Model
The Stages of Readiness for Change Model (Figure 4-5, Chapter 6, Appendix I,
I-l, I-2, I-3) clears up some of the misconceptions many people have about stopping
smoking. For example, some individuals who want to stop feel discouraged because they
have had difficulty stopping in the past. Participants in the FSO describe that they negate
the positive changes they've made in previous quit attempts because they are still
smoking. People tend to judge their success as black or white, smoking or not smoking.
In actuality, success with a chronic condition such as nicotine dependence is cumulative.
Examining earlier quit attempts to identify cues and learn how to manage them in the
future can be especially instructive. Participants begin to understand that stopping
smoking is a process rather than an event. Motivation and determination develop over a
period of time.
Figure 4-5
Recovery often means stopping an addictive relationship with a chemical with which one
has been intimate for decades. While the goal is to become successfully abstinent, it may
take several weeks or months to adequately prepare for stopping smoking. People in the
preparation stage are still using tobacco, but they are on their way to becoming
nonsmokers. They may have overcome tremendous obstacles
in resolving ambivalence in the previous stage of contemplation, but it is unrealistic
to expect people to stop just because they have knowledge or insight about
their use. It is helpful to recognize that this is a very powerful addiction, one that
requires the same treatment afforded other chronic diseases such as alcoholism and
other drug dependency.
The Stages of Readiness for Change Model acknowledges progress and describes
the tasks that will need to be undertaken to move successfully through the stages.
Participants can assess what stage they are in; record it on the Assessment Form,
and use this information as they eventually prepare their own Individualized
Treatment Plan (Appendix Q-6).
Stop Smoking Techniques
For many people, a helpful way to begin the process of quitting is to break up the
associations that have been built between specific cues and the act of smoking. A
technique for disarming these cues is to isolate the addiction from the trigger situations.
For example, the phone rings and a smoker reaches for a cigarette before
picking up the phone. Although we don't ask people to throw away their phones,
we suggest that the using behavior (smoking) be isolated from the pleasantries associated
with it (speaking on the phone). As a result, people begin to practice speaking
on the phone without smoking.
By changing other behaviors, such as adopting a smoke-free policy in the home
and car, additional cues are eliminated while the person prepares to stop smoking.
A benefit of making one's home and car smoke-free is that the person must think
about whether he or she really needs that cigarette. This permits an examination of
how much genuine pleasure is gained from the use of nicotine? As the built-up cues
become separated from the smoking, the person learns how to be comfortable and
to feel normal without cigarettes in situations where smoking had been the norm.
Having the home and car smoke-free helps isolate the addiction, and the consumption
of cigarettes may decrease dramatically.
Each participant begins to identify and list triggers that lead to smoking on the
Triggers Worksheet (Appendix Q-5, page 5). Examples from the Triggers
Worksheets are presented for the group to review. Coping mechanisms, alternative
activities and new skills are offered as ways to disarm these triggers.
Other techniques, such as relaxation training and the 4-D's (Delay, Deep breathe,
Drink water and Do something different) are reviewed and practiced in the workshop.
Participants also receive supportive materials from the National Cancer Institute,
Hazelden Educational Materials, Nicotine Anonymous and other sources.

Treatment Planning
The individualized Treatment Plan is developed by each participant to meet his or her
own needs and lifestyle. Each person is challenged to reflect on the support system
presently available, and on potential new resources such as Nicotine Anonymous, other
recovering smokers, or a support group that could be initiated for staff at the treatment
facility. Individuals than develop a plan for implementing the necessary changes to move
to the next stage of stopping smoking.
Following the FSO workshop, attendees are offered follow-up phone calls at
approximately 2 weeks, and 2, 4, 6, 8, 10, and 12 months. While it is satisfying to hear
someone has stopped smoking, it is also gratifying to be in contact with, and support,
those who are committed to making the changes necessary to stop smoking, but are
struggling through the process.
Nicotine dependence is a cunning, baffling, and powerful addiction, and while nicotine
dependence among program staff is a central problem in policy development, it is, more
importantly, a critical personal and professional issue. Helping staff members deal with
their own nicotine dependence can be a major benefit for them and their facility.
Employment Concerns

How a treatment center plans to move forward in implementing a tobacco-free policy
while preserving their greatest asset-their staff-is perhaps the biggest challenge. Can a
program require that all employees be free of tobacco use during work hours? What is to
be done about staff members who violate the tobacco-free policy? How does a tobacco-
free policy affect the hiring process?

Employment Policy Rationale
There are a number of situations in which is essential that an employee be an nonsmoker
or, for that matter, a non-(active) alcoholic. These include h=jobs that involve the
treatment and prevention of nicotine dependence and alcoholism.
In New Jersey, a law designed to protect smokers from job bias acknowledges that
employers also need the option, in given work situations, to require that employees not
use tobacco products (Appendix-N; Figure 4-6). It makes sense that an employer be
allowed to insist that a person treating or preventing nicotine dependence be free of the
drug (Slade, 1993). As tobacco use and nicotine dependence become more fully
integrated into the addictions treatment paradigm, programs will need to prepare their
treatment staff to be able to address this issue with their clients without compromise.
An employer shall not refuse to hire, discharge, or take any adverse action against an
employee because that employee does or does not smoke or use tobacco products, unless
the employer has a rational basis for such actions which is reasonably related to the
employment (emphasis ours) (NJSA 34:6B-1 through NJSA 34:6B-4, PL 1991,
Chap.207).
Figure 4-6

Job Announcements
Notice that the “facility is tobacco-free” can be included in all job announcements. This
alerts potential employees to the expectations of their job regarding tobacco use during
work hours, and allows for discussion of the policy during the interview process. Among
candidates for clinical positions, previous training and experience in nicotine dependence
treatment can also be reviewed. It is appropriate, as well, to discuss training opportunities
for staff to gain competency in nicotine addiction treatment. By noting the tobacco-free
policy in the job announcement, facilities lend further legitimacy and commitment to
providing genuinely comprehensive addictions treatment.
Employee Assistance Program (EPA) Model
The tobacco-free policy needs to clearly state the evidence of tobacco use by staff during
work hours is a violation of policy, just as evidence of alcohol or drug use is a policy
issue in many organizations (Figure 4-7). How the policy is enforced for staff is an
important issue in the process of implementation. When policy violations begin to result
in interference with one’s job performance, the problem must be addressed.
NO Evidence of Tobacco Use
Carrying paraphernalia such as matches, lighters, or wearing articles of clothing with Figure 4-7 Many programs have adopted an EAP model to deal with the use of alcohol and other drugs by employees. In this model, counseling, assessment and referral services are provided to employees for mental health problems, chemical dependency, or other issues that interfere with job performance. Using an EAP model in the tobacco-free policy means that non-compliance by staff is framed as a job performance issue. Activities that supervisors may observe include using tobacco on the grounds or clandestine use of tobacco in the building, taking too many or taking longer breaks (if tobacco use is permitted during work hours or during the transitional period to become tobacco-free), leaving one’s work station to smoke (such as going off-site to smoke leaving clients unattended), or demonstrating evidence or tobacco use during work hours (such as returning from breaks smelling of smoke or having tobacco products or paraphernalia in one’s possession). An EAP approach would be to offer the staff person assistance whenever his or her job performance is compromised by the use of tobacco. An EAP referral can be the intervention offered by the employer in an effort to maintain the staff person’s employment with the facility. For some staff members, the bottom-line possibility of termination may provide the motivation necessary to address their tobacco use. An EAP approach demonstrates a facility’s understanding of the addictive nature of tobacco and the importance of providing a consistent message about tobacco use. It recognizes that nicotine dependence treatment is on a par with the treatment of alcohol and other drugs of dependence.

Source: http://www.voicesunited.net/documents/tobacco/manual/Chapter%204.pdf