Lynda remembers why she smoked. “I didn’t care that it could cause lung cancer, I just liked the feeling,” says the client of Milwaukee-based Meta House, a treatment center that helps women struggling with drug and alcohol addiction to reclaim their lives. “But as your mind clears, as you’re living clean and sober, something tends to click: ‘Let me try this and see how I feel.’”

With Meta House’s help, Lynda quit smoking (last name withheld for confidentiality).

“It’s an amazing feeling to be able to breathe again, to be able to not smell like smoke, to be able to feel good in the morning and wake up and not feel all groggy,” comments Lynda. “The Meta House staff taught us how it would be effective to our recovery.”

It hasn’t always been that way at Meta House, where one staff member says she used to take clients outside to smoke—a decades-long practice among behavioral health facilities that persists across the country today.

“That was a way of coping, I guess,” the staffer recalls.

Smoking remains the leading preventable cause of disease and death in the United States. People with behavioral health issues smoke nearly half the cigarettes across the nation. Tobacco products kill approximately half those who use them, and people with behavioral health issues are more likely to die prematurely from smoking than from their other addictions or mental illness.

Not so relaxing

For years, tobacco companies have touted their products as ways to relieve stress and anxiety, when, in fact, research shows smoking worsens mental and physical health: A meta-analysis of 63 research studies involving more than 8 million patients found that people who smoke or formerly smoked are at higher risk of suicidal ideation, suicide plan, suicide attempt and suicide death, according to the online medical journal PLOS One.

But clients like Lynda now speak up to reduce the stigma and encourage others to quit smoking. When Meta House went tobacco-free years ago, it started by reaching out to its own staff.

Christine Ullstrup, MSW, the organization’s vice president of clinical services, sought support from the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) —which is part of the UW School of Medicine and Public Health—to help train staff on how to quit tobacco use and how to help their clients do the same. Ullstrup says the employees gave a mixed response.

“I remember being gathered in this circle, with people who had their arms crossed and closed body language,” she shares. “Some closed to [the idea of quitting tobacco]. And now, some of those who were closed to it are non‑smokers.”

That same staff member who used to take clients out to smoke saw her doctor and quit smoking.

“They thought I had smoked so long I couldn’t [quit],” she notes. “But I was there to say that I could do it. Other agencies are going smoke-free now, too, and I think it’s great. I really do.”

A new dawn

Ullstrup is encouraged that the Wisconsin Department of Health Services (DHS) has created a new rule that strengthens standards regarding tobacco treatment and smoke-free facilities. Specifically, subchapter DHS 75.24(7) requires Wisconsin providers who treat substance-use disorders to formulate plans by October 2022 to outline the service’s approach to assess and treat concurrent tobacco-use disorders and have a policy about the facility’s smoke‑free environment.

“Meta House totally supports including tobacco diagnosis and treatment in the new DHS 75,” says Ullstrup. “It is imperative that we treat tobacco addictions the same as other addictions and help people live longer, healthier lives. Ethically, we believe there isn’t another choice. We feel more supported in our work by our community partners than when we started this journey.”

Rules like Wisconsin’s DHS 75 vary widely from state to state. According to the Public Health Law Center, as of March 15, 2020, 11 states required tobacco-free grounds for most mental health facilities, and five states required tobacco-free grounds for most substance-use recovery facilities. As of 2017, only 39 percent of mental health treatment facilities in the United States provided cessation counseling. And only about a quarter of these facilities offered medications to help people quit tobacco use.

Yet, some states have been successful at changing that trend. For example, in 1999, New Jersey became the first state to require residential treatment centers to assess and treat tobacco dependence, and to maintain smoke-free campuses as a matter of maintaining licensure. A year later, all 30 residential programs surveyed provided some tobacco-dependence treatment and half had tobacco-free grounds. Eighty-five percent of the programs accepted the state’s offer to provide free medications to quit tobacco use, reaching more than 2,326 clients. Seventy-seven percent of all clients smoked, and 65 percent of the people who smoked reported they wanted to stop or cut down tobacco use, according to an article in the Journal of Substance Abuse Treatment by researchers led by Jill Williams, MD, director, Division of Addiction Psychiatry, Rutgers University. And yet, many of those gains in New Jersey have atrophied due to lack of enforcement.

Barriers to overcome

If so many people in addiction recovery and mental health treatment smoke cigarettes, why are so few of their behavioral health care providers treating it?

Sometimes, clinicians across the country are naturally more concerned about treating an urgent issue—such as suicidality or heroin use, explains Tyson Rittenmeyer, director of clinic-based programs at Journey Mental Health in Madison. Even when clinicians offer to help clients quit tobacco use, some patients are not interested or motivated to quit.

Tyson Rittenmeyer
Tyson Rittenmeyer of Journey Mental Health, which screens, diagnoses and treats tobacco-use disorder along with other behavioral health issues.

Some behavioral health leaders fear that people who are addicted to nicotine will go to other health care facilities that allow smoking, vaping and chewing, but do not address nicotine addiction. As the theory goes, they fear fewer patients could impact the bottom line.

Wisconsin regulations formerly prohibited recovery centers from taking a patient solely to help them quit their addiction to nicotine, despite the fact that tobacco use kills more residents than any other addiction and is associated with higher suicide risk.

“In Wisconsin, we were actively blocking people from getting treatment,” Rittenmeyer notes. “What does that say?”

He’s happy the state has changed the policy, and that Journey screens, diagnoses and treats tobacco-use disorder along with other behavioral health issues.

Level playing field

“Statewide policy is the solution,” Williams said during a webinar hosted by the Public Health Law Center. “If all treatment programs have the same standard—an equal playing field—you won’t have issues like that. Studies have shown that when regions or states implement these policies, admissions do not go down. So, it’s not true that no one will come to treatment. It raises the level and quality of care, in my opinion, because we should all have tobacco-free grounds.”

The Wisconsin quality assurance team will check to make sure recovery centers are following the DHS 75 updates that take effect in October. A few centers, like Journey, are electing to go above and beyond the new requirements.

“Our patients have a conversation with the clinician about willingness to quit, how nicotine impacts their life, their mental illness or substance-use disorder or both,” Rittenmeyer says, adding that Journey clinicians offer counseling and refer for medications to quit tobacco use.

“A lot of times, it comes down to basic motivational interviewing,” he explains. “Often, they aren’t ready for that or say, ‘I’m not here for that.’ So, as a clinician, you have to be savvy to come back to that, to move them from pre-contemplative to contemplating quitting. If we have consumers in the active quitting stages, it’s about supporting them.”

That can mean treating the core source of adverse childhood events or other pain the patient may be working through, and uncover reasons why they will want to get clean and live healthier.

Rittenmeyer says it also means creating an environment where people trying to quit don’t see others using the products, to avoid getting triggered to crave nicotine. That’s why Journey created a tobacco-free campus in 2018, led in part by psychiatrist Eric Heiligenstein, MD.

To embolden such changes, Heiligenstein worked with leaders to garner buy-in, secured a grant to pay for medications to help people quit tobacco use, formed a committee, ensured the clinicians were ready to treat tobacco-use disorder, and encouraged staff who smoked to quit. He says it’s key to set rules for the campus and to decide who will enforce them.

Journey employees posted signs and notified everyone the policy was coming. Once the policy took effect, they occasionally told people who smoked on the campus to please stop or they’d have to leave. Rittenmeyer says they rarely had to ask people not to smoke or vape, but they did have to monitor the campus for tobacco trash and contraband that could trigger people trying to quit tobacco or stay smoke-free.

“We can feel a slight culture shift,” Ullstrup observes. “Not all is smooth sailing. It is a constant battle in our residential facility, with clients bringing in vape products. We try to reward good choices and do the best we can to monitor the milieu to support overall health.”

Successful cessation

Journey and Meta House offer support to help clients quit tobacco use.

“In day treatment, a lot of people have quit smoking. A lot of the staff have quit smoking. I chose to quit because I wanted to and needed to. I was having asthma issues,” shares Angela (last name withheld), who was a client. “It’s awesome because they taught us what the nicotine did.”

One patient at Libertas, a rehabilitation center in Wisconsin, notes that smoking was the key trigger for his other behavioral health challenges, but he didn’t realize it at first.

“This was my sixth time through a 30-day treatment, and I relapsed; they were all smoking facilities,” recalls Ronnie (last name withheld). “Every [treatment facility] ought to be non-smoking because I know how smoking and addictions go hand-in-hand.”

Ronnie says the fact that Libertas offered him help to quit smoking in a smoke-free environment made all the difference for him to change his life for the better.

Wisconsin’s role

UW-CTRI is offering resources and training to help recovery centers embrace, meet and surpass the requirements of DHS 75. These efforts are supported by funding from the DHS.

It’s an extension of the Wisconsin Nicotine Treatment Integration Project (WiNTiP) founded about 15 years ago by Heiligenstein and David “Mac” Macmaster—who quit smoking and drinking 50 years ago and has dedicated his career since then to helping people with behavioral health issues to quit smoking, and to do so systematically. WiNTiP was a driving force to alter DHS 75 and to offer people like Lynda, Angela and Ronnie the resources they need to successfully quit.

“The new rule is saying that if you’re providing treatment for any substance use, tobacco use now fits in there,” Macmaster explains. “This is a big chance, a big opportunity that has in the past been denied.”

WiNTiP Project Manager Karen Conner, MPH, of UW-CTRI, notes, “People with substance-use disorders want to quit, and we’ve seen time and again that they can quit with evidence-based help. What’s more, they tell us that nicotine is a trigger for their other addictions—and quitting nicotine helps them quit all substances of abuse.”

Ullstrup adds, “This is the right thing to do. We do a disservice by not doing it. It’s going to be hard, but it’s worth the journey, it’s worth the obstacles because we’re changing lives and the health and wellness of the clients we serve.”

She continues, “I’ve lost too many friends to nicotine addiction. It’s a journey that needs to be made.”

Lynda shares, “There’s a greater chance of me staying clean because I don’t have any mood-altering substances going into my body. Nicotine is a mood-altering substance—it’s just legal!”

By Chris Hollenback
This article appears in Quarterly magazine.