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Published on May 28th, 2014 | from CAMH

Tobacco research and treatment: We’ve come a long way

by Wayne Skinner, CAMH Deputy Clinical Director, Addictions Programs

World No Tobacco Day is on May 31, and I’ve been reflecting how attitudes to cigarettes have drastically evolved in recent history.

When I started working as a therapist at the Addiction Research Foundation (which became part of CAMH in 1998) in the late 1970s, I can remember a client, proudly receiving my praise for having successfully withdrawn from heroin, taking out a cigarette and saying, “Now if I could only quit these!”

In those days, we didn’t even ask people if they smoked when we took drug histories. Indeed, it was more common than not for counsellors to offer clients a cigarette as a friendly way of starting a session.

A lot has changed in the intervening years, and much of that is actually the result of work that happened right here, going back to the 1970s and 1980s.

The Addiction Research Foundation did have a strong line of tobacco research. I remember one scientist, Lynn Kozlowski, going around and collecting cigarette butts that he and his team analyzed to prove that people smoking filtered cigarettes were getting as much toxins in their lungs as smokers of unfiltered cigarettes.

Not long after these cigarette butt fieldwork studies, Lynn approached me, in my role as head of outpatient services, to see if we could offer some counselling services for patients of the chest clinic at Toronto Western Hospital, smokers who had been diagnosed as being pre-emphysemic.

If they could quit smoking, they could prevent or delay severe, potentially fatal lung disease.  But they were having real trouble stopping – and staying stopped.

So they asked the Addiction Research Foundation for help. We developed a treatment model that included nicotine gum and brief cognitive behavioural therapy.

In those days, the patient needed to get a prescription for nicotine gum, which we usually had them arrange with their family physician.

What we learned

  • We quickly learned that quitting smoking was not an easy task.
  • We also realized that we had to add tobacco to the list of addictive substances we asked clients about.
  • One other outcome of this collaboration with Lynn was that we made it part of the routine to ask clients at intake about their tobacco use (over 85 percent were smokers), and also to compare smoking with the drugs that were bringing them into treatment, including how pleasurable the drugs were and how hard they thought it would be to quit.

Our clients indicated that when it came to pleasure and reward, drugs like heroin and cocaine are more powerful than drugs like cannabis and tobacco.

But when it came to the drug that would be the hardest to quit, tobacco came out on top.

We wrote up these findings and were able to get them published in the Journal of the American Medical Association. (See: Comparing Tobacco Cigarette Dependence with Other Drug Dependencies)

Nicotine addiction: Just leave it alone?

We then started to talk to our colleagues in the treatment field about the importance of offering treatment for nicotine addiction, and did we ever get pushback!

Many professionals felt we just didn’t get it: That we were showing a complete lack of compassion for people trying to get off really serious drugs such as heroin, cocaine, and alcohol.

And here we were, wanting to talk to them about giving up the last thing they had to hold on to.

We looked at the treatment literature for guidance. While there was strong opinion among service providers that tobacco use should be left alone when folks came in for addiction treatment, the problem was, there was no evidence, one way or another, on which to base an informed view.

There have been parallel views to just leave tobacco alone in mental health treatment, where tobacco was sometimes doled out to residential patients and used as a behavioural reward.

Still, we felt that clients at least needed to be offered choices, based on reliable information about the harms of smoking and the benefits of stopping, and that those options ought to be part of what is offered in addiction treatment programs.

Since then, the evidence (pdf) has come in that those who are able to stop smoking along with the primary drugs that they seek help for have the best clinical outcomes.

We also know now that smoking can be a powerful relapse trigger for people who want to stop other forms of drug use, so that it doesn’t exist in its own little bubble disconnected from everything else.

Thirty years ago, in Canada, the Addiction Research Foundation was the first addiction program to offer treatment where tobacco use alone was good enough to get you in.

Fast forward to today

CAMH leadership in treatment and knowledge exchange for nicotine is recognized nationally and internationally, and is in evidence on the ground in our smoking cessation clinics and training initiatives for healthcare professionals.

Our approach to treatment is anchored in three strong traditions:

  1. Evidence-informed care
  2. Harm reduction
  3. Respecting the right of each person to make their own decisions and chart their own course to health and wellbeing

The role of the hospital is not just to know about the evidence, but to also provide healthy environments and create effective tools and methods that allow recovery and healing to happen.

Recent research clearly demonstrates a link between smoking cessation and better treatment outcomes—reduced depression, anxiety, and stress, and improved positive mood and quality of life compared with continuing to smoke. This is an especially important job when dealing with a behaviour that on average robs the habitual user of 10 years of life and is a huge factor in other addiction and mental health problems.

Looking ahead

A few weeks ago, I was in New York City for a brief visit. Walking along Fifth Avenue, I came to Madison Square Park, a modest sized space with trees in bloom, full of people on a sunny day….  There was a sign at the entrance: No smoking within the park.

Sign for Madison Square Park next to a No Smoking in the Park sign

No smoking in the park? You bet I noticed this sign!

I was curious about what I would see as I walked through. To my surprise, I didn’t see one person smoking. I didn’t even see a cigarette butt on the ground. I was amazed that could happen in New York City.

Do you think the day will come when there will be a social consensus on not smoking in outdoor public spaces in Toronto and other cities in Ontario?

Going forward, from a harm reduction perspective, what role should CAMH play in preventing tobacco use and in helping people quit?

*Top photo: Creative Commons licence

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