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Local Services Bulletin No. 2006 - 10: Tobacco Dependence Practice Guidelines

Date Issued: December 6, 2006

RECIPIENTS

  • All OASAS Certified Providers

PURPOSE

The purpose of this Local Services Bulletin is to provide information to the field regarding the steps that need to be taken to convert to a tobacco-free program. The NYS Department of Health Tobacco Control Program is working to make this effort a success by developing training curricula specifically designed for direct care staff (i.e., physicians, nurses and counselors). The Department of Health will also be able to assist in the transition to a tobacco-free environment by making available nicotine replacement therapies to OASAS programs.

BACKGROUND

OASAS partnered with the American Cancer Society and Alcoholism and Substance Abuse Providers of NYS, Inc. (ASAP) in 2003 to start a dialog in regard to the OASAS provider system going tobacco-free. In the ensuing years, the partnership has grown to include over 15 member groups.

In 2004, the OASAS Commissioner issued an advisory to the field which contained the OASAS Tobacco Dependence Policy statement. This Statement reflected OASAS' belief that it is the responsibility of chemical dependence prevention and treatment providers to address all addictions. Furthermore, given the important role it plays in promoting healthy lifestyles, OASAS' prevention and treatment provider community is uniquely positioned to advocate for community-wide acceptance of tobacco dependence prevention, treatment and recovery.

In August of 2005, a letter was issued to all NYS chemical dependence providers informing them of the significant changes that are underway as part of the revised Part 800 Chemical Dependence regulations. The letter, which highlighted the proposed tobacco-free policy changes, included the following:

  1. All chemical dependence treatment and prevention providers must provide tobacco-free facilities, grounds and vehicles. "Tobacco-free" means that the use of tobacco is not permitted in any form indoors or on the facility grounds. This differs from "smoke-free" where tobacco products, such as snuff and chewing tobacco are allowed.
  1. These regulations will pertain to all OASAS certified entities.
  1. All chemical dependence service providers must screen all patients for tobacco use at admission as part of the initial assessment and this must be noted in the record.
  1. All chemical dependence providers must incorporate tobacco dependence into the addiction treatment plan in the same manner as other chemical diagnoses are incorporated.
  1. Pharmacotherapy should be offered and/or allowed for use by patients who are being treated for their tobacco dependence.
  1. Tobacco dependence education must be incorporated into the chemical dependence treatment provider program of services. Every facility shall include tobacco education in their weekly educational sessions in addition to alcohol, drug, HIV, and other health issues education.
  1. Staff should have specific tobacco dependence training as part of their educational program at the facility. Staff are prohibited from smoking at the facility or having tobacco related paraphernalia in their work environment.

OASAS realizes that, in order for a program to successfully go tobacco-free, a well thought out plan of action is needed which builds-in time for staff, patients and referents to adapt to this change. This Local Services Bulletin offers pertinent information and guidance which can assist providers in successfully implementing this programming effort.

A tobacco-free Chemical Dependence Unit must:

  1. Acknowledge the profound challenges tobacco creates for the addictions treatment community.
  2. Establish a leadership group or committee and secure the commitment of the administration.
  3. Develop a tobacco-free policy.
  4. Establish a policy implementation timeline.
  5. Conduct staff training.
  6. Provide recovery assistance for nicotine dependent staff.
  7. Assess and diagnose tobacco dependence in patients and address this in treatment planning.
  8. Incorporate tobacco education into its patient education curriculum.
  9. Establish ongoing communication with AA/NA and referral agents about these changes.
  10. Require staff to be tobacco-free.
  11. Establish tobacco-free facility and grounds.
  12. Implement tobacco dependence treatment throughout the program.


A model plan for staff to implement these changes must start with:

Agreement on goals and timetable
Careful planning and emphasis on education
Establishment of policies and procedures
Support at the top and a cooperative spirit
An understanding that staff must be tobacco-free during the hours of employment
Using treatment (and not just coercion) when dealing with tobacco issues
Taking pride in the policy
Patience: keep your eyes on the prize


The components of a model timetable for implementing tobacco-free changes include:

@2 years - obtain cooperation, agreement and support of administration and medical leadership and inform staff

@6 months through 2 years - hold regular in-service trainings with staff, encourage smoking staff to quit, develop policies and procedures (regarding violations, consequences, Nic Anonymous meetings, visitor restrictions [dress, smell] and staff restrictions)

@ 6 months - initiate weekly tobacco education groups for patients and make available self-help materials for patients and staff

@5 months - increase intensity of staff education and send staff to relevant conferences

@4 months - discuss imminent changes with other departments: admissions, housekeeping, security, maintenance, administration, dietary, to ensure their support and cooperation

@3 months - policies and procedures finalized and accepted, staff members aware of the changes, smoking area on the unit reduced in size, purchase a carbon monoxide monitor (detects when a patient has been smoking)

@2 months - unit medical director discusses plans with physicians; current patients are informed of changes and process feelings, begin a second weekly group on smoking cessation - attendance required

@1 month - patients informed that smoking times will be reduced

@ 3 weeks - support departments plans finalized:

dietary: will provide carrot sticks, juices
housekeeping: planning deep cleaning
security: agrees to search all visitors for contraband
maintenance: research smoke detectors in the bathrooms
activity therapy: planning extra morning exercise group
admissions: will discuss smoke-free policy with all new patients and families prior to admission
pharmacy: will order a supply of nicotine replacement therapies
medical/nursing staff familiarize themselves with carbon monoxide monitor

@ 2 weeks - begin informing new patients of tobacco-free policy prior to admission and hold community meetings for patients to discuss policy

@ 1 week - be aware that problems can start (patient and staff anger, staff question wisdom of policy)

Start day - collect all cigarettes, lighters

Copies of all active Local Services Bulletins are available on the OASAS Web Site.

/s/ Henry Zwack
Executive Deputy Commissioner