Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 

ADVISORY

3 Issue • 10 Volume • 1 201March 

Tobacco Use Cessation Policies in 

Substance Abuse Treatment: 

Administrative Issues 

This Advisory provides substance use disorder 

(SUD) treatment program administrators with a 

brief introduction to implementing tobacco-free 

policies and practices in treatment settings. This 

Advisory is meant to be read with the Advisory 

Tobacco Use Cessation During Substance Abuse 

Treatment Counseling.1 That Advisory presents 

information on tobacco use cessation by clients in 

SUD treatment. The information is summarized 

below: 

● Tobacco use among SUD treatment clients. 

Clients entering treatment for an SUD are 

more likely to be dependent on nicotine 

than are members of the general public. 

For example, 75 percent of people ages 12 

and older who received substance abuse 

treatment at a specialty facility in the past year 

reported smoking cigarettes in the past month, 

compared with 24 percent of the general 

population.2

 Despite these statistics, most 

substance abuse treatment programs do not 

address smoking cessation. 

● Health effects of tobacco use. From 2000 

to 2004, cigarette smoking and exposure to 

secondhand smoke resulted in at least 443,000 

premature deaths each year.3 Tobacco use 

is the leading cause of preventable disease 

and deaths in the United States.4

 It can cause 

diseases of the lungs and cardiovascular 

system as well as many cancers. 

● Health benefits of tobacco use cessation. 

The most important effects of tobacco use 

cessation are the beneficial health changes, 

such as lowered risk of respiratory infection, 

coronary heart disease, stroke, and lung 

cancer, as well as cancers of the mouth, throat, 

esophagus, bladder, cervix, and pancreas.4, 5 

● Symptoms of nicotine withdrawal. Nicotine 

withdrawal symptoms include an intense 

craving for nicotine, tension, irritability, 

frustration, mild depression, reduced ability to 

experience pleasure (anhedonia), dysphoria, 

anxiety, anger, restlessness, difficulty 

concentrating, and increased appetite. Some 

symptoms, such as craving, mild depression, 

and anhedonia can last months to years.6 

● Tobacco use cessation treatment by 

SUD counselors. Treatment for nicotine 

dependence requires screening, assessing for 

readiness to change tobacco use behavior, and 

intervention. Counselors should ask clients 

who smoke or use other tobacco products 

about their interest in quitting while in 

substance abuse treatment.7 

● Effective treatment approaches to tobacco 

use cessation. Counseling and nicotine 

use cessation medications are the primary 

approaches used and are often used together. 

Both over-the-counter and prescription 

medications are available. Quitlines are also 

a valuable resource for people who want to 

quit using tobacco. Internet assistance (http:// 

www.smokefree.gov) can be helpful. 
 

2 

ADVISORY
 

Tobacco Use Cessation Efforts 

in Substance Abuse Treatment 

Programs 

A growing body of research supports incorporating 

tobacco use cessation into substance abuse treatment: 

●		Incorporating smoking cessation into treatment 

for alcohol and drug abuse does not jeopardize 

recovery.8
 

●		Eliminating tobacco use is associated with 

decreased use of other abused substances (12 

studies).8
 

●		Including smoking cessation interventions in 

substance abuse treatment is associated with a 

25-percent increase in the likelihood of maintaining long-term alcohol and drug abstinence.9 

In line with these findings, some State governments 

have begun mandating that substance abuse treatment 

facilities be smoke free.10, 11 

Barriers to Implementing 

Tobacco Use Cessation in 

SUD Treatment 

Despite the morbidity associated with smoking 

and the well-established health benefits of stopping 

tobacco use, treatment providers have been reluctant 

to address tobacco use cessation with clients 

in substance abuse treatment. Some barriers to 

addressing tobacco use cessation during treatment 

include the following: 

●		Tobacco use is an accepted part of the addiction 

treatment and recovery culture. People in early 

recovery have used cigarette smoking as a means 

of bonding with one another. Treatment staff 

members and clients may also bond through 

smoking. 

●		Many treatment providers believe that attempting 

to stop smoking during substance abuse treatment 

can jeopardize recovery. 

●		Traditionally, major life changes (including 

quitting smoking) during early recovery were 

discouraged for fear of causing relapse, even 

though quitting other substances is not treated 

as a major life change.
	

●		Many treatment program staff members smoke 

cigarettes, although, as role models for clients, 

staff members who smoke set a negative 

example.
	

Implementing a Tobacco Use 

Cessation Policy 

The Substance Abuse and Mental Health Services 

Administration suggests enforcing a tobacco-free 

norm at treatment facilities. Some programs must 

obey State or local tobacco-free workplace mandates. 

Normally, creating and adopting a tobacco-free policy 

involve several steps, such as assessing need, planning, promotion, implementation, and evaluation.12 

To develop the new policy, administrators can review 

current organizational policies and practices that may 

tacitly support tobacco use by staff and clients, such 

as allowing staff members to smoke with clients or 

referring to breaks as “smoking breaks.” A new 

tobacco-free policy can cover the following issues:13 

●		Purpose of the policy and its fit with organizational 

values 

●		Individuals affected by the policy (e.g., clients, 

staff members, guests)
	

●		Areas in which tobacco use is not permitted (e.g., 

indoors, parking lots, facility vehicles) 

●		Consequences of not complying with the policy 

(e.g., warnings, negative comments on job 

evaluations) 

●		Support available to smokers who want to quit 

(e.g., counseling, medications)
	

●		Date new policy takes effect (alert staff 1 to 4 

months in advance)
	

It is important to clearly communicate the policy 

to everyone. Communication can take place at 

meetings, during trainings, and through notices, 

Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 
3 

Tobacco Use Cessation Policies in Substance Abuse Treatment: Administrative Issues 

March 2011, Volume 10, Issue 3 

emails, and other channels. Staff members should 

be allowed to ask questions and make comments. 

Employee handbooks, policy manuals, and other 

resources will need to be revised to reflect the 

new policy. 

Staff members’ support when making major 

policy changes is helpful, but policies such as 

no tobacco use on facility grounds can be 

instituted without staff approval. A leadership 

group that includes a cross section of program 

staff members who support the change can help 

introduce the policy and help address concerns 

at all levels. 

Staff members may benefit from additional 

education about the health dangers of tobacco 

use and the availability and the effectiveness 

of medications and counseling approaches. Many 

resources are available for staff training in tobacco 

use cessation methods as well as for clients and 

staff members who want to stop tobacco use. 

Developing Clinical Guidelines

for Treating Tobacco Dependence 

Staff members will need guidance on addressing 

tobacco use cessation with clients. Exhibit 1 lists 

some suggestions. 

Resources 

Technical Assistance Publication 31: Implementing 

Change in Substance Abuse Treatment Programs 

has general information on introducing institutional 

changes (http://www.kap.samhsa.gov/products/ 

manuals/pdfs/TAP31.pdf). 

Making Your Workplace Smokefree: A Decision 

Maker’s Guide provides step-by-step directions on 

how to develop and implement tobacco-free policies 

and details the costs, consequences, and benefits of a 

tobacco-free workplace (http://www.joechemo.org/ 

cdcguide.htm). Other resources for a tobacco-free 

workplace are at http://www.cdc.gov/nccdphp/dnpao/ 

hwi/toolkits/tobacco/index.htm. 

The American Cancer Society’s toolkit for clean 

indoor air can be downloaded from http://www 

.cancer.org/acs/groups/content/@pennsylvania/ 

documents/document/ciaccpdf.pdf. 

Notes 

1 Substance Abuse and Mental Health Services Administration. (2011). 

Tobacco use cessation during substance abuse treatment counseling. Advisory, Volume 10, Issue 2 2 Office of Applied Studies. (2008). National Survey on Drug Use and 

Health, unpublished data. Rockville, MD: Substance Abuse and 

Mental Health Services Administration. 3 Centers for Disease Control and Prevention. (2008). Smokingattributable mortality, years of potential life lost, and productivity 

losses—United States, 2000–2004. MMWR, 57(45), 1226–1228. 

Exhibit 1. Clinical Policies and Practices for Tobacco Use Cessation 

Policies for Client Care Practices 

Screen all clients for tobacco use and 

provide strategies if they are ready to quit. 

Ask about tobacco use at intake and in subsequent visits. 

Include tobacco use cessation in treatment planning. 

Document tobacco use and cessation 

attempts in the clinical record. 

Revise clinical forms to report client tobacco use and tobacco use cessation 

approaches available in the program or available through referral. 

Record tobacco use and attempts to quit in all charting from intake through 

discharge and continuing care. 

Address tobacco use cessation in 

educational sessions. 

Educate clients on the health dangers of smoking and about approaches to 

quitting (i.e., quitlines, medications, and counseling). 

Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 
ADVISORY

4

 Centers for Disease Control and Prevention. (2004). The health consequences of smoking: A report of the Surgeon General. Atlanta, 

GA: National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health. 5

 Centers for Disease Control and Prevention. (1990). U.S. Surgeon 

General’s report: The health benefits of smoking cessation. HHS 

Publication No. (CDC) 90-8416. Atlanta, GA: Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and 

Health. 6

 Dani, J. A., Kosten, T. R., & Benowitz, N. L. (2009). The pharmacology of nicotine and tobacco. In R. K. Ries, S. C. Miller, D. A. 

Fellin, & R. Saitz (Eds.), Principles of addiction medicine (4th ed., 

pp. 180–193). Chevy Chase, MD: American Society of Addiction 

Medicine. 7

 Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., 

Curry, S. J., et al. (2008). Treating tobacco use and dependence: 

2008 update. Clinical Practice Guideline. Rockville, MD: Public 

Health Service, U.S. Department of Health and Human Services. 8

 Baca, C. T., & Yahne, C. E. (2009). Smoking cessation during 

substance abuse treatment: What you need to know. Journal of 

Substance Abuse Treatment, 36(2), 205–219.

9

 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 Counseling and Clinical 

Psychology, 72(6), 1144–1156. 10 Foulds, J., Williams, J., Order-Connors, B., Edwards, N., Dwyer, M., 

Klein, A., et al. (2006, Fall). Integrating tobacco dependence treatment and tobacco-free standards into addiction treatment: New 

Jersey’s experience. Alcohol Research & Health, 29(3), 236–240. 11 New York State Office of Alcoholism and Substance Abuse. (n.d.). 

Tobacco independence. Retrieved August 11, 2010, from http://

www.oasas.state.ny.us/tobacco/index.cfm 12 Centers for Disease Control and Prevention. (n.d). Implementing 

a tobacco-free campus initiative in your workplace. Retrieved 

August 5, 2010, from http://www.cdc.gov/nccdphp/dnpao/hwi/

toolkits/tobacco/index.htm 13 American Cancer Society. (n.d.). Clean indoor air: A toolkit for 

going smoke-free in Pennsylvania. Retrieved August 11, 2010, 

from http://www.cancer.org/acs/groups/content/@pennsylvania/

documents/document/ciaccpdf.pdf

SAMHSA Advisory

This Advisory was written and produced under contract numbers 270-04-7049 and 270-09-0307 by the Knowledge Application 

Program (KAP), a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Center for Substance Abuse 

Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and 

Human Services (HHS). 

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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2011). Tobacco use cessation policies 

in substance abuse treatment: Administrative issues. Advisory, Volume 10, Issue 3.

HHS Publication No. (SMA) 11-4636Admin

First Printed 2011

SAMHSA Advisory

Tobacco Use Cessation Policies in Substance Abuse

Treatment: Administrative Issues