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December 2013

Tobacco and nicotine addiction; “Deaf” clinicians; Resources


On December 10, 2013, the National Institutes of Health released a press statement with the headline: “Stimulant-addicted patients can quit smoking without hindering treatment.” The sub-headline said: “New NIH study dispels concerns about addressing tobacco addiction among substance abuse patients.” 

With the new year just around the corner, this is a good time for healthcare providers and addiction treatment professionals in particular, to resolve that 2014 will be the year we start taking nicotine addiction seriously. If you are still a tobacco user, could this not be a New Year’s resolution and gift to yourself which keeps giving every day and will pay dividends many times over?

Easy enough for me to say, as I have never been a tobacco user.


It is time to face the facts that nicotine addiction or tobacco use disorder is as deadly as other addiction illness.

According to the Substance Abuse and Mental Health Services Administration in 2008:

  • 63 percent of people who had a substance use disorder in the past year also reported current tobacco use, compared to 28 percent of the general population.
  • “Smoking tobacco causes more deaths among patients in substance abuse treatment than the substance which brought them to treatment. “
  • Check again that second bullet point: Patients may have gone into addiction treatment for cocaine, alcohol, heroin or some other drug, but smoking tobacco is what causes more deaths than the very drug that caused them to seek treatment in the first place! (Nicotine addiction is not the ‘kinder, gentler’ drug addiction, it is the killer for many.)
  • Despite this, most addiction treatment programs do not address smoking cessation.

National Institute on Drug Abuse (NIDA) Director Dr. Nora D. Volkow said: “However, treating their tobacco addiction may not only reduce the negative health consequences associated with smoking, but could also potentially improve substance use disorder treatment outcomes.”

–> Here are the CONCLUSIONS in the Abstract of the study this press release was trumpeting:

“These results suggest that providing smoking-cessation treatment to illicit stimulant-dependent patients in outpatient substance use disorder treatment will not worsen, and may enhance, abstinence from non-nicotine substance use.”

Dr. Theresa Winhusen, from the University of Cincinnati College of Medicine and first author on the study said: “These findings, coupled with past research, should reassure clinicians that providing smoking-cessation treatment in conjunction with treatment for other substance use disorders will be beneficial to their patients.”


Review the DSM-5 criteria for Tobacco Use Disorder.

You’ll notice that tobacco (or more accurately, nicotine) causes the same kind of addiction disorder as other drugs. How is it then, that many still consider it different from other drug addiction?

Tobacco Use Disorder is defined by the following criteria in DSM-5:

A problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring in a 12-month period:

1.   Tobacco is often taken in larger amounts or over a longer period than was intended. 

2.   There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.

3.   A great deal of time is spent in activities necessary to obtain or use tobacco.

4.   Craving, or a strong desire or urge to use tobacco.

5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).

6.  Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use). 

7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use. 

8.   Recurrent substance use in situations in which it is physically hazardous (e.g., smoking in bed).

9.   Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.

10.   Tolerance, as defined by either of the following:

a.  A need for markedly increased amounts of tobacco to achieve the desired effect.

b.  A markedly diminished effect with continued use of the same amount of tobacco. 

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for Tobacco Withdrawal)

b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

(DSM-5, page 571 in hard covered edition)


American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.

Winhusen TM, et al: “A randomized trial of concurrent smoking-cessation and substance use disorder treatment in stimulant-dependent smokers.” J Clin Psychiatry. 2013 Dec 10. 


When a clinician or program decides that tobacco use disorder and nicotine addiction are the same addiction illness as alcohol, heroin, cocaine or any other substance use disorder, the first impact is on the counseling staff.

The new edition of The ASAM Criteria (2013) has a special section on Tobacco Use Disorder pp. 367-392.  To read an article from the co-authors of this section, Drs. Blank and Karan, go to the “WHAT’S NEW” tab at, and then click on Read full article: New Section in The ASAM Criteria: Tobacco Use Disorder.


Examine this case example from The ASAM Criteria chapter on Tobacco Use Disorder

Case 6 (page 391)

TH is a 50-year-old addiction counselor who works at a residential addiction treatment center. The center has decided that they are going to begin treating tobacco addiction along with all other addictions. The staff is not going to be able to smoke at all at work, and will not be allowed to come to work smelling of tobacco smoke.   TH is in recovery from addiction to alcohol and pain medications. He has been sober for 23 years and always felt that tobacco was not part of his disease. He feels that he has extra rapport with patients since he goes out smoking with them on breaks.   TH has often advised patients who wanted to stop smoking that they should wait at least a year before they even consider stopping, because “it is too hard to quit more than one thing at a time.”   TH has been told by his doctor that his frequent bouts of bronchitis are directly related to his smoking, and that he needs to stop before he does permanent damage to his lungs. TH is about 40 pounds overweight and fears that if he stops smoking, he will gain even more weight. He has never tried to quit, and is angry about his workplace forcing him to stop.

This is one of seven case studies that illustrate treatment and placement principles. What is interesting in Case 6 is that counselor TH “ feels that he has extra rapport with patients since he goes out smoking with them on breaks.It is true that many programs have stopped smoking inside the treatment program building, but will have a smoking gazebo on the grounds where counselors like TH can “bond” with clients while joining them smoking.

My mischievous poke at such programs is to ask where is the alcohol gazebo where counselors can share a beer; or the heroin gazebo to shoot up together? And what about a benzodiazepine gazebo where patients can bring their favorite tranquilizer to share with each other?


Note this rhetorical question: Would it be OK for a counselor who had a beer or glass of wine at lunch to lead a group session with alcohol on his or her breath?

I can think of no program or team that would be OK with this. Yet the same program would think nothing of letting a counselor smoke together with clients and then lead group treatment reeking of tobacco smoke.

So as more and more programs start to take nicotine addiction seriously, the same expectations for tobacco users will apply to alcohol using staff: if you use your drug in breaks at work, you cannot do individual or group counseling with either alcohol or tobacco odor on your breath or clothing. This means:

  • Either don’t drink or smoke in breaks while on the job
  • Or if you do, there has to be a long period of time for all evidence of use to dissipate before counseling. For smokers, that means a change of clean clothes as tobacco smoke does not quickly dissipate.

For counselors like TH in the case study, the inconvenience of having to change clothes after every smoke break may ultimately just get too much to handle.  Programs in transition are providing smoking cessation programs for staff first, before moving the whole program to tobacco-free for patients.


Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.


A few weeks ago in Australia, I visited my childhood neighbor who has known me since I was three years old. I’ll call her Mrs. Martin – not her real name. She was telling me how hard it has been to talk with her oncologist and be heard. Joan has ovarian cancer which went into remission but recently metastasized to her bowel and is now inoperable.

The chemotherapy left her weak, emotionally and physically drained, and using a walking stick. Until now, she has never had to use a stick even though approaching 90 years of age. Joan’s physician wanted her to undergo more chemotherapy despite the patient’s wishes to have a break from the awful treatment. Joan was ready to take whatever path her cancer would lead her, but she wanted some quality of life and not treatment that was worse than the disease.

Somehow she could not be heard. It needed her son to be intensely assertive for the oncologist to hear Joan’s wishes.

When I visited Mrs. Martin, she had just returned from ten days at an alternative holistic health retreat where they use a combination of massage, diet, colonics and who knows what else. Before I arrived she had already gone for a morning walk without any sight of a walking stick. She greeted me with: “I’m a new woman.” She was optimistic, beaming, feisty and totally different from her son’s report a few weeks earlier, which sounded as if she was on her deathbed.

The cancer isn’t cured and she will have darker days. But I was first inspired by the faith and positive attitude Joan beamed; and then sobered by how hard it is for patients to be heard by well-intentioned, but “deaf” physicians and healthcare providers who do not engage and listen to their clients and patients.

Joan was scheduled to see her oncologist two days after our visit. This time, she will present in a totally improved condition to her physician who will perhaps wonder what worked. Joan stated she would not be telling the physician where she has been and what she’d been doing that brought her back to such a state of well-being.

He wouldn’t understand, she mused. And I tend to agree with her.

sharing solutions

I often receive emails and questions from providers and clinicians on what to do when a payer or managed care company is not using The ASAM Criteria correctly. I also receive questions in reverse about providers or programs not using The ASAM Criteria correctly.

1. “Using” the ASAM Criteria means different things to different organizations and providers. So take a look at the article I wrote for Counselor Magazine: “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do”.  You can access it at Click on “WHAT’S NEW.”  Scroll down to the article/link for the November-December 2013 edition of Counselor Magazine.  Article is entitled: “How to Really Use the New Edition of the ASAM Criteria: What to Do and What Not to Do.”  (There are other articles there as well.)

2. Perhaps you are a provider or payer having concerns about how The ASAM Criteria are being used. Feel free to complete an Incident Report. There’s one for patients, providers and programs and a different one for payers and managed care organizations. Go to Click on FAQ tab.  Search for: How do I report incidents of misuse of The ASAM Criteria? 

3. There are opportunities for training on The ASAM Criteria. This happens via eTraining modules or via onsite workshops and conferences nationally.  Learn about eTraining at the RESOURCES & TRAINING tab.  For workshops and conferences near you, click on the EVENTS tab at 

4. There also exists an enhanced web version of the ASAM book.  Click on the BOOK & WEB tab.  Take a test drive with the informative video.

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