Addictions Advisor: Smoking Bans and SUD Treatment — A Social Work Perspective
Combustible tobacco use, commonly referred to as cigarette smoking or smoking, kills more than 480,000 Americans each year and remains the leading cause of preventable death in the United States (Centers for Disease Control and Prevention, 2019a). Smoking rates are higher among marginalized and oppressed groups, including the LGBTQ+ communities, people of color, poorer people, and people living with mental health and/or substance use challenges (Centers for Disease Control and Prevention, 2019b). This disparity is of no surprise given that tobacco companies have been found to routinely target marginalized and oppressed groups for tobacco sales and consumption (Lee, Henriksen, Rose, Moreland-Russell, & Ribisl, 2015). It is very important to increase smoking cessation resources, supports, and services available and offered to those who have been most targeted and impacted by deadly combustible tobacco use.
When it comes to the high smoking prevalence rates among people living with mental health and/or substance use challenges, many public health officials and managed care organizations (MCOs) charged with overseeing Medicaid-funded behavioral health systems have set their sights on addressing smoking in behavioral health care settings. A variety of policies and practices have been enacted in behavioral health care systems across the country with the noteworthy goal of supporting smoking cessation. It is of great importance, however, that smoking cessation policies and practices align with core social work values and principles such as engaging “people as partners in the helping process” and honoring their autonomy, right to self-determination, and “capacity and opportunity to change and to address their own needs” (NASW, 2017). There is a major difference between offering support for a behavior change and forcing a behavior change. Even with the most admirable goal, any paternalistic policy or practice, especially those accompanied by punitive measures for noncompliance, has no place in behavioral health care. Sadly, this is precisely what we see happening in Philadelphia.
On January 1, 2019, amid an opioid-related overdose death crisis that has killed more than 3,200 Philadelphians over the past three years, Philadelphia public health officials and the city’s nonprofit Medicaid MCO Community Behavioral Health (CBH) announced the implementation of a contractually mandated new smoking policy for its network of 80 inpatient addiction treatment facilities (Newall, 2019; Kopp, 2018). This policy prohibits people receiving Medicaid-funded inpatient addiction treatment from going outside to smoke while in treatment. Officials cited high smoking prevalence rates, the long-term deadly nature of combustible tobacco use among people living with substance use disorders, and limited research suggesting that people may have a greater chance of sustained abstinence from other drugs if they quit smoking as the rationale behind the policy (Prochaska, Delucchi, & Hall, 2004). The systemwide policy in practice means that for Philadelphia’s poorest and most marginalized individuals seeking addiction treatment—the same population proven targeted by tobacco companies and shown to be most impacted by deadly tobacco use—going into inpatient addiction treatment now requires an immediate readiness to go smoke-free, at least for the stay.
Policy Short Sight
But what if people seeking to address immediately life-threatening fentanyl and other drug use do not have the goal of quitting smoking at the time of treatment engagement? What becomes of the person who says they want to enter into treatment to stop injection drug use that poses an immediate overdose death risk but are not ready to tackle quitting smoking at this time?
Policies such as smoking bans leave no space for individuals not in a place of smoking cessation readiness in the Medicaid-funded inpatient addiction treatment system, and the collateral consequences have been a grave injustice.
For the addiction treatment providers strong-armed by CBH into implementing this policy as a contractual requirement for remaining in network, they were left to deal with continued smoking among those entering into treatment who did not share the imposed goal of quitting smoking. As a predictable outcome of prohibition, an underground market for cigarettes quickly emerged in inpatient addiction treatment settings, and, for an untold number of people, violating the smoking ban policy resulted in administrative discharge from treatment (Feldman, 2019). It took more than six months after policy implementation and mounting pressure from advocates for CBH to issue a memo to inpatient addiction treatment providers urging them not to discharge people from treatment for getting caught smoking (CBH, 2019). However, this forced smoking ban policy continues to leave addiction treatment providers stuck between a rock and a hard place. Treatment providers are forced with the choice of turning a blind eye to smoking inside the building, developing secretive workarounds to allow for people to go outside to smoke, or continuing to administratively discharge people who violate the policy and put the safety of others in jeopardy (Feldman, 2019).
Discharging people out of addiction treatment for exhibiting symptoms of what brought them into treatment has long been a senseless practice, and punishment for not sharing the same treatment goals that policymakers have set for them is injustice. To discharge someone from treatment simply because they are demonstrating not being at a place of immediate readiness for smoking cessation is foolish and harmful. At a time of unprecedented death from drug overdoses that can kill within minutes, punishing people for not harboring the goal of immediate smoking cessation when seeking addiction treatment is the last thing we need.
Person-centered care requires that we meet people right where they are and support them with their goals for themselves, their well-being, and their lives. Respecting the dignity and worth of people requires that we work alongside them and honor their autonomy, right to self-determination, and innate capacity to make changes for themselves and address their own needs in their own time. From a social work perspective, imposing a goal upon people and then excluding or punishing them for not sharing or achieving that goal flies in the face of our Code of Ethics and the social work profession’s guiding values and principles. While behavioral health systems absolutely ought to offer, encourage, and even incentivize smoking cessation, particularly among those most targeted and impacted by deadly combustible tobacco use, we must not stray from that which guides our work. We also must remember our charge to challenge social injustice “with and on behalf of vulnerable and oppressed individuals and groups of people” (NASW, 2017).
When a paternalistic policy is imposed upon only our poorest, most marginalized, and most oppressed individuals at a time when they are most vulnerable and at risk of immediate death, social workers must push back. When people are discharged from treatment for not sharing the same treatment goal that policymakers have imposed upon them, social workers must push back. Our nation’s most marginalized and oppressed individuals have already been unjustly targeted for and impacted by combustible tobacco product use; to exclude this same population from addiction treatment only furthers the harm and gross injustice.
— Brooke M. Feldman, MSW, is a person in recovery, social worker, and social justice activist who focuses on bringing about policy and practice change at the intersections of mental health, substance use, and social justice issues. She currently manages two office-based opioid treatment programs for CleanSlate Outpatient Addiction Medicine in Philadelphia and serves on the board of Angels in Motion, a Philadelphia-based harm reduction and recovery support organization.
Centers for Disease Control and Prevention. (2019b). Tips from former smokers: Burden of cigarette use in the U.S. Retrieved from https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html.
Community Behavioral Health. (2019, June 20). Community Behavioral Health: Provider notification administrative discharges from residential drug and alcohol treatment settings. Retrieved from https://cbhphilly.org/wp-content/uploads/2019/06/notice_2019-06-20_smoke-free_policy.pdf.
Feldman, N. (2019, September 26). Smoking ban at drug rehab centers fuels black market for cigarettes, safety issues. Retrieved from https://whyy.org/articles/smoking-ban-at-drug-rehab-centers-fuels-black-market-for-cigarettes-safety-issues/.
Kopp, J. (2018, December 28). Philly bans tobacco use at addiction treatment programs. PhillyVoice. Retrieved from https://www.phillyvoice.com/philly-bans-tobacco-use-addiction-treatment-programs-smoking-cigarettes-vaping/.
Lee, J. G. L., Henriksen, L., Rose, S. W., Moreland-Russell, S., & Ribisl, K. M. (2015). A systematic review of neighborhood disparities in point-of-sale tobacco marketing. American Journal of Public Health, 105(9), e8-e18.
NASW. (2017). Code of ethics. Retrieved from https://www.socialworkers.org/about/ethics/code-of-ethics/code-of-ethics-english.
Newall, M. (2019, December 11). Hey, Philly, this many overdose deaths is not normal. Just ask any other city. The Philadelphia Inquirer. Retrieved from https://www.inquirer.com/news/columnists/philadelphia-pittsburgh-overdose-deaths-harm-reduction-opioid-crisis-20191211.html.
Prochaska, J.J., Delucchi, K., Hall, S. M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144-1156.