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Tobacco use in the treatment trenches

Updated: May 30, 2021

The following commentaries appeared in Alcoholism and Drug Abuse Weekly in the opinion section “From the Field”

Tobacco use in the treatment trenches, 4/27/2020

As reported here (ADAW October 14, 2019) and elsewhere, recently I have focused much of my time to raising alarms about the very high rates of smoking among addiction treatment and recovery populations. In addition to archival research, I have conducted a series of key informant interviews to better understand the roots of our field’s ongoing reluctance to address this issue. These interviews with national leaders in the alcohol and drug field confirmed that when presented with statistics about the very high rates of cigarette smoking among treatment and recovery populations there is widespread consternation about the resulting tobacco-related mortality and morbidity. Paradoxically, however, this concern has not translated into strong remedial action.

Rather than viewing tobacco addiction as a core element of the organization’s mission to treat substance use disorder, tobacco use disorder is seen as something to be outsourced to tobacco control agencies or NGO’s like the American Cancer Society. Rather than incorporate tobacco addiction into assessment protocols and treatment regimes, tobacco use is either prohibited completely or accommodated through policies and practices that allow clients to continue to smoke.

The very high incidence of tobacco use among treatment and recovery populations prompted one research report in Nicotine & Tobacco Research to conclude with a call to action:

The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control.

In order to gain firsthand knowledge about how clients in treatment and individuals in recovery experience cigarette use, a series of three focus groups were convened in California. One was held at a medication assisted outpatient treatment program in an agricultural region that serves a largely Latino population. Two focus groups were held at a recovery community center (RCC) in an urban setting that serves African-American and Latino members. Thirteen of the 25 participants from the RCC were concurrently receiving outpatient and residential treatment services. In total, of the 36 focus group participants 39% were African-American, 33% were Latino, 14% identified as Caucasian and 8% were Asian Pacific Island. Six percent declined to identify their race.

Most of the participants reported that they had been struggling with their addiction to cigarettes for years both before, during and after seeking treatment/recovery from alcohol or other drugs. In many cases the use of cigarettes was/is inextricably interwoven with their other addictions, as well as their treatment and recovery episodes. Partial responses to three questions posed to participants are presented below.

How was smoking cigarettes connected to your alcohol or drug use?

Many participants spoke of initiating cigarette smoking during childhood. In one case as early as age 8. The overwhelming majority described families in which smoking and alcohol or drug use was commonplace. Tobacco use was inextricably linked to alcohol or drug use.

Drinking and tobacco go hand-in-hand. The only time I smoke is a cigarette after smoking crack. Meth kinda freezes your lungs and cigarettes are a break from the pipe. Cigarettes prolong the high, especially with weed. Cigarettes were my gateway drug. I always need a cigarette after hitting heroin. When I didn’t have drugs I used cigarettes. I only smoke when I am in my addiction. I had quit smoking but started again when I got into rehab. Smoking tobacco brings balance to drinking and helps you pace yourself.

Have you tried to quit or reduce? Describe your experiences quitting or reducing?

Almost all participants described numerous attempts to reduce or quit cigarette use, almost always unsuccessful.

One is too many and 100 are not enough. I had quit but started again when I started to go to AA meetings. I can quit easily in prison but start again when I come out. In prison drug thinking stays with you because there are drugs around, but nobody smokes so nicing ( Nic: to crave nicotine. Pronounced "nick") doesn’t last. Always trying to reduce or quit. When the California prison ban started we smoked apple seeds, banana peels and used chewing tobacco. Cigs are crazy expensive. Got to budget for food, housing and smokes. Smoking cigarettes is how my addiction shows up today. I’m at 3-4 packs a day. No intention to quit; grandma smoked from 17 to 102. I would like to be not addicted to anything but I’m not ready.

Do you think that quitting cigarettes might endanger a person’s recovery from alcohol or drugs?

Participants report that cigarette smoking in treatment or recovery is as important to them as cigarette use in their addiction. Many expressed surprise and disappointment that they still smoke cigarettes, though well into their recovery from alcohol/drug use.

Cigarettes allow you to maintain some control over your life. Smoking is a big part of the day in rehab. The breaks from group are smoking breaks. It’s calming. Maybe we are just substituting the cigarettes for drugs. Not all houses are smoke-free. Smoking bans in rehab are counterproductive. My parole agent couldn’t believe that you could get kicked out of rehab for smoking tobacco. What you learn in rehab about staying away from drugs is not transferable to quitting cigarettes. Cigarettes don’t put you in jail. Maybe just deal with one substance at a time. Some rehab programs give you smokes. After the first 10 days in rehab I was told to no more cigarettes.

John de Miranda is an independent consultant who has worked in the alcohol and drug problem field for most of the 45 years that he has been in long-term recovery. He is recipient of a 2019 Tobacco Harm Reduction scholarship from Knowledges Action Change ( He can be reached at; 650-218-6181.

Dirty words: smoker, vaper, harm reductionist? 10/14/2019

During the course of my career in the alcohol and drug problems field I have observed, studied and taught about the power of words to clarify, obscure or demonize both practices and people. Thirty years ago I learned the hard way that suggesting that my colleagues listen to, rather than reject, criticisms from the harm reduction community would have me labeled a “drug legalizer”.

We have witnessed how words like reefer and dope have given way to medicinal cannabis and edibles. Similarly, beliefs about cigarette smoking have changed dramatically from a widely sanctioned social practice to an activity marginalized by society through policy and public opinion. Smokers have increasingly been marginalized as personae non gratae. Some of that stigma is now being transferred to people who vape.

About a year ago I began to focus my work on the high incidence of mortality and morbidity among treatment and recovery populations because of addiction to the use of combustible tobacco, i.e. cigarette smoking. Like the two founders of AA people with substance use disorder are more prone to die from tobacco-related causes than alcohol or drug-related problems.

I have learned a lot since then about the large numbers of former smokers worldwide who have transitioned from cigarettes to e-cigs. When an individual makes this change in their behavior they likely continue their addiction to nicotine but reduce the pulmonary ingestion of harmful by-products by more than 90%. Dr. Michael Russell an early advocate for tobacco harm reduction (THR) but it simply, “People smoke for nicotine but die from the tar.” Nevertheless, the public perception of e-cigs is rife with misinformation. A majority of Americans mistakenly believe that e-cigs are as dangerous as cigarettes; many disapprove of and even vilify vapers as somehow vaguely undesirable.

Over dinner a few months ago I mentioned to a friend that I was involved in a project investigating e-cigs as a strategy to reduce smoking rates among those in treatment or recovery. At the mention of the word “vaping” his expression turned quickly to one of disapproval. He said he found this to be a disgusting habit. His contempt for vapers was quite obvious.

What is clear however is that e-cigs have helped many people end their addiction to cigarettes and in so doing have dramatically improved their health status. Yet a recent survey of 259 residential substance use disorder programs in California found that 98% prohibited or limited the use of these products. While many programs offer or recommend cessation counseling programs, the six-month quit rates for these as well as nicotine replacement therapy (patches, inhalers) are not particularly impressive.

The adoption of harm reduction approaches to tobacco use disorder (TUD) for people in treatment or recovery is further complicated by the recent rash of illnesses and deaths now thought to be largely linked to the use of contaminated street products in e-cigs. Compounding the issue is the recent rise in vaping among youth, which has allowed the public, led by the media, to conflate use by young people with use by adults. As one veteran THR advocate told me, “When we have an outbreak of salmonella we don’t ban all food. We identify and isolate the tainted hamburger or lettuce and warn the public. E-cigs have been used without problems by millions of people for more than ten years. Like the crack-baby “epidemic” this is simply another drug panic!”

There’s a saying “Don’t let perfect be the enemy of good.” The field’s early rejection of drug harm reduction was an example. We wanted complete abstinence for our clients. Ideological purity trumped day-to-day practicality. Simply reducing use or switching to less harmful drugs was anathema. Only recently, have we begun to turn the corner on the stigma associated with harm reduction strategies such as medication assisted treatment.

As I talk with colleagues about my new focus there is widespread agreement that TUD among people in treatment and recovery requires more serious attention. The question of how to tackle the problem should include proven public health approaches that reduce risk and harm.

John de Miranda is an independent consultant who has worked in the alcohol and drug problem field for most of the 45 years that he has been in recovery. He is recipient of a 2019 Tobacco Harm Reduction scholarship from Knowledges Action Change ( He can be reached at; 650-218-6181.

Nicotine addiction and substance use disorder treatment: The Philadelphia story, 2/14/2019

The Philadelphia Department of Behavioral Health and its leadership have a well-deserved reputation for pioneering recovery-oriented systems of care. Effective January 1, 2019 the agency initiated an aggressive policy to address the problem of nicotine addiction among those receiving substance use disorder (SUD) services in contracted facilities. The policy covers 9 detox facilities, 32 short-term rehabilitation programs, 31 long-term rehab programs and 8 halfway houses.

Behavioral Health Commissioner David T. Jones, a passionate proponent of the policy believes that aggressively addressing tobacco addiction will dramatically improve all treatment outcomes.

According to Jones:

“Smoking among Philadelphians who have a substance use or alcohol problem is at 69% and 48% respectively. By comparison smoking among Philadelphians not using drugs or alcohol hovers at around 22%. Tobacco use kills more of our citizens than both opioid overdose and gun violence together.” (1)

The Substance Abuse and Mental Health Services Administration reports that adults with SUD account for more than 18% of all cigarettes smoked in the United States. (2) For persons entering SUD treatment smoking estimates as high as 97% have been reported. (3) One research report in Nicotine & Tobacco Research concluded:

The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control. (4)

Behavioral health populations are actually more likely to die from smoking related illness than the illegal drugs and alcohol that they are ingesting, according to Jones. The Philadelphia Behavioral Heath Department estimates that smoking-related conditions comprise 39% of deaths among opioid users, 40% among cocaine users and 49% among alcohol users.

Despite very high rates of morbidity and mortality linked to smoking in this population, efforts by treatment providers and funders to respond have been largely ineffectual. While the majority of private and publicly-funded treatment programs maintain a nominal “smoke free” environment, provisions are often made to accommodate a client’s tobacco addiction offsite or in specially-designated areas. In more enlightened programs referrals to smoking cessation external resources may occur or onsite educational classes often conducted by guest speakers from the anti-tobacco sector.

The Philadelphia effort is far more comprehensive. Key elements include:

• A detailed assessment of the client’s nicotine addiction during admission.

• Incorporation of nicotine addiction treatment into the SUD treatment plan.

• Robust staff training designed to provide tangible, evidence-based treatment tools to enable staff to assist clients in their tobacco-related recovery while concurrently providing treatment for their admitting diagnosis.

• Medication to manage nicotine withdrawal for tobacco users including e-cigarette users.

Historically, the conventional wisdom has been that addressing tobacco addiction would somehow jeopardize SUD recovery. Today we know that smoking is often part of a drug use ritual that can trigger relapse post-treatment. According to Jones, “quitting smoking while undergoing SUD treatment can increase a person’s chances of sustaining recovery after discharge by 24%.”

It is sometimes said that innovation comes slowly to the alcohol and drug treatment sector. For example, it has taken decades for treatment professionals to embrace harm reduction practices that act as a lower threshold for recovery engagement. Let’s hope that more treatment providers and systems will follow the trail blazed in the City of Brotherly Love by offering tobacco addiction services to clients in their care.


1. Personal Communication 1/23/2019.

3. McClure, E. A., Campbell, A. N., Pavlicova, M., Hu, M., Winhusen, T., Vandrey, R. G., . . . Nunes, E. V. (2015). J Subst Abuse Treat, 53, 39-46. doi:10.1016/j.jsat.2014.12.007

4. Guydish, Joseph, et al., Smoking prevalence in addiction treatment: a review, Nicotine & Tobacco Research, vol 13, 401-411.

John de Miranda, Ed.M., is an independent consultant specializing in substance use disorder, recovery and disability issues. He can be reached at 650-218-6181;

Vaping is harm reduction for smokers with mental illness, 5/28/2018

During my final hospitalization for alcohol use disorder the medical director of the service, himself in recovery, strongly warned me against quitting cigarettes for a minimum of five years into sobriety. Granted this was more than 40 years ago, and considered the conventional wisdom then, but as I was smoking 4 packs of unfiltered cigarettes a day, it was really bad advice, perhaps bordering on malpractice! I eventually did quit and, even though 4 decades have passed, my primary care physician continues to monitor my lungs with an annual CT scan.

According to some studies roughly half of the cigarettes consumed worldwide are smoked by persons with mental health diagnoses including substance use disorder. It is believed that tobacco use and related morbidity can reduce life expectancy 15 to 20 years for many in these categories. The growing realization of this epidemic-within-an-epidemic has generated an urgency for the development of smoking harm reduction and cessation strategies tailored to the needs of persons with mental health disorders.

The last 20 years have seen considerable sophistication in the development of cessation services targeting tobacco addiction. These abstinence-based strategies, however, may have only limited utility for individuals who use tobacco to manage mental health symptoms and drug cravings. Just as we have added harm reduction elements to our addiction treatment toolbox, investigating harm reduction approaches to assist those addicted to tobacco is both timely and necessary.

Such an effort is currently underway at the University of California, San Francisco Department of Community Health Systems.

Using a Harm Reduction approach, the objective of this research intervention in to evaluate and compare the efficacy of a variety of intervention strategies chosen by subject-participants. A corollary aspect of this project is to also test whether intensity of intervention impacts smoking behavior change. Adult persons with severe and persisting behavioral health disorders are the target of this research project.

Subjects will be recruited from behavioral health programs in San Francisco and assessed for their interest in making some change in their combustible tobacco use. They will have the opportunity to choose from the following strategies: cessation, reduction, conventional nicotine replacement strategies (nicotine patch or gum), electronic devices, nicotine inhaler or FDA approved medications (Varenicline, Buproprion).

Participants will also be asked to meet weekly with a counselor for up to six months. Subjects will have the option to trial and switch intervention choices. They will also be invited to participate in a weekly support group. Subjects will receive a gift card (likely $10) for each visit. The project may also utilize some form of cell phone technology to provide daily reminders of the chosen intervention. Subjects will be asked to complete a monthly inventory of their change efforts and to complete a carbon monoxide breathalyzer assay to measure current combustible tobacco use.

Principal Investigator, Kevin McGirr, RN, MS, MPH, believes that support for harm reduction approaches is long overdue and will complement traditional cessation approaches.

This research will provide us with an opportunity to examine two intervention questions: 1. will enabling access to all the choices of tobacco intervention that are available in the general population and 2. will enhancing the intensity of intervention similarly to what is available to persons with other drug and alcohol problems succeed in modifying combustible tobacco use?

The research is supported by the Foundation for a Smoke-Free World, an independent research and advocacy organization the funding for which is provided by Philip Morris International.

John de Miranda, Ed.M., is an independent consultant specializing in substance use disorder, recovery and disability issues. He can be reached at 650-218-6181;

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