PTTC Post Article - November 2021

Seize the Day: Improve Treatment Outcomes with Tobacco-Free Recovery

By Cecilia M. Fichter DeSando, MPM


Seize the Day: Improve Treatment Outcomes with Tobacco-Free Recovery

If you knew that you could improve recovery outcomes, decrease the incidence of substance use recurrence, reduce depression, anxiety, and stress and reduce health disparities for those with behavioral health disorders with one proven therapeutic strategy would you do it? The evidence is in. Tobacco-Free Recovery is a key strategy for improving outcomes for individuals with behavioral disorders.

Research Findings

A 2014 systematic review and meta-analysis of 26 studies found that smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The researchers found that the effect size seems as large for those with psychiatric disorders as those without and the effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders. A 2010 study using 9-year prospective data from 1185 adults in outpatient substance use treatment, found that having stopped smoking at 1 year predicted both long-term abstinence from substance use and remission status 9 years later. In addition, a 2017 nationally representative, prospective longitudinal investigation found that cigarette smoking is associated with increased risk of substance use disorder relapse, with the researchers concluding that the evidence supports concurrent smoking cessation and substance use treatment as the most beneficial approach.

Not only does tobacco use complicate substance use treatment but several studies have found that cannabis use is implicated in increased cigarette smoking and decreased cessation. A 2020 publication cites recent longitudinal data finding that cannabis use is associated with increased risk of cigarette smoking initiation, persistence, and relapse among adults in the United States.
Tobacco-related Disparities

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly 25% of adults in the United States have a mental health or substance use disorder (i.e., behavioral health condition), and these adults consume almost 40% of all cigarettes smoked by adults in the United States. People with behavioral health conditions die about five years earlier than people without such conditions, more than 50% from tobacco-attributable diseases and individuals with serious mental health disorders who smoke die almost fifteen years earlier than individuals without these disorders who do not smoke.   Tobacco smoke interacts with many medications by influencing the absorption, distribution, metabolism, or elimination of the medication, potentially causing an altered pharmacologic response. Individuals who smoke may require higher doses of medications and upon cessation may need reduced medications. To reduce the health disparities and to improve treatment outcomes, SAMHSA recommends the adoption of tobacco-free facility/grounds policies and the integration of tobacco treatment into behavioral health care.  Doug Tipperman, MSW is the Tobacco Policy Liaison at SAMHSA Office of Policy Planning and Innovation. In his role, Doug provides training and technical assistance to support the integration of tobacco cessation in behavioral health settings and he provided updated statistics, clarity, and technical assistance for this article. “While overall smoking rates have been decreasing the smoking rates for persons with behavioral health conditions is about twice that of the rest of the population. Despite the heavy disease and mortality burden, smoking cessation interventions are not routinely offered within behavioral healthcare settings. By providing tobacco treatment in behavioral healthcare we are providing best practice that creates an opportunity to not only reduce health disparities but to also improve treatment outcomes.”  Many individuals with behavioral health conditions want to quit smoking, several surveys show that 44-80 % of individuals in addiction treatment are interested in quitting cigarettes and yet in 2019, 57.4% of mental health and 42.4 of substance abuse treatment facilities reported that they did not offer cessation counseling. 72.7% of mental health and 67.6% of substance abuse treatment facilities reported not offering nicotine replacement therapy (NRT).
Small Group Talking

Tobacco-Free Recovery Resources

To increase the number of behavioral health facilities that provide tobacco cessation, SAMHSA  developed “Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings.”  and “Implementing Tobacco Cessation Programs for Individuals with Serious Mental Illness.”  These electronic guides for clinicians and program directors contain an overview of the challenges associated with tobacco cessation and the benefits of being tobacco-free for individuals as well as those of a tobacco-free workplace. They also include tips that treatment settings can use to implement their own tobacco cessation programs.

National Center of Excellence for Tobacco-Free Recovery

In February of 2018 SAMHSA awarded a 5-year grant to the University of California, San Francisco to establish the National Center of Excellence for Tobacco-Free Recovery. The Center provides technical assistance, training, and supportive resources to:

  • Promote the adoption of tobacco-free facilities, grounds, and policies
  • Integrate evidence-based tobacco cessation treatment practices into behavioral health and primary care settings and programs
  • Educate behavioral health and primary care providers on effective evidence-based tobacco cessation interventions


All Hands In a circle


A key change strategy used by the National Center of Excellence is to convene State Leadership Academies for Tobacco-Free Recovery. These Leadership Academies mobilize a statewide collaborative to develop effective strategies to reduce the prevalence of tobacco dependence among people with behavioral health disorders. To date, 22 states have convened a Leadership Academy and are implementing their action plans.  The Center provides specialized technical assistance on national, state, and local levels, including one-on-one phone consultation, educating primary care providers, behavioral health care providers, and other stakeholders on ways to advance efforts to reduce tobacco use among persons with behavioral health disorders and free CME/CEU online learning opportunities for live and recorded webinars.



American Lung Association Public Health Roadmap

Many providers, clinicians, and prevention practitioners may be reluctant to undertake what often seems a daunting task of implementing tobacco-free recovery policies and programs. The American Lung Association (ALA) has compiled a step-by-step guide “Public Health Roadmap: Tobacco Use Disorder (TUD) Treatment Integration in Behavioral Health Settings.”  ALA has developed tools and gathered partner resources to support this work, based on feedback from key stakeholders, including state and local tobacco control program staff, behavioral health program staff, clinical care providers, and other content experts. This collection of resources is intended for State Tobacco Control Program staff and other public health professionals, working with providers, organizations, agencies, and systems serving people with mental illness and substance use disorders to treat tobacco use and dependence.
Rx for Change

Many clinicians do not feel qualified to provide tobacco cessation services and many organizations are concerned about extensive costs and training time. The School of Pharmacy and Medicine at the University of California, San Francisco,  has developed a no-cost training program “Rx for Change: Clinician-Assisted Tobacco Cessation”. This program was designed to address an identified need to enhance the tobacco cessation education of health professionals. Rx for Change, which draws heavily from the Clinical Practice Guideline for Treating Tobacco Use and Dependence, is a comprehensive, turn-key program for training students and licensed clinicians in virtually any health professional field. The teaching strategies are varied and all materials have been externally reviewed and are updated continuously to reflect current science for the treatment of tobacco use and dependence.  The following versions are available:

  • Rx for Change: Clinician-Assisted Tobacco Cessation (“5 A’s” approach)
    Our complete curriculum, including all core and optional modules, requires approximately 10 hours for implementation. These materials are applicable to any health profession. Our most common implementation scenario is 6 to 8 hours, which includes all core modules plus the Forms of Tobacco module. Slides are supplemented with ancillary handouts, role-playing with case scenarios, and video segments. 6 hr minimum for core modules and role-playing/videos.
  • Rx for Change: Ask-Advise-Refer (brief intervention)
    Ask patients about tobacco use, advise patients to quit, and refer patients to other resources for additional assistance - such as the toll-free tobacco quitline, local group programs, and internet-based programs. This approach is applicable to any profession but is particularly relevant to assistants of clinicians, such as medical assistants, dental assistants, and pharmacy technicians, for whom implementation of the 5 A’s would be inappropriate. Lecture slides are supplemented with video counseling sessions modeling the Ask-Advise-Refer approach. Standard and dental versions are available. 1.5 hrs each.


Tailored versions are available for:

  • Psychiatry (4 hrs)
  • Cardiology (1 hr)
  • Mental Health Peer Counselors (2 hrs)
  • Respiratory Care (4 hrs)
  • Surgical Care (1.5 hrs)

The Great American Smokeout

As with all plans for change, it may be difficult to know where to start. The American Cancer Society tells us to "start with day one." For more than 40 years, the American Cancer Society has hosted the Great American Smokeout on the third Thursday in November. This year’s event will be celebrated on November 18, 2021. The Great American Smokeout is an opportunity for people who smoke to commit to healthy, smoke-free lives – not just for a day, but year-round. The Great American Smokeout also provides an opportunity for individuals, community groups, businesses, health care providers, and others to encourage people to use the date to make a plan to quit, or plan in advance to initiate smoking cessation on the day of the event. The American Cancer Society acknowledges that quitting isn’t easy and takes time, support, and a plan. They encourage tobacco users that they don’t have to quit in one day, but to start with day one. As prevention and treatment professionals, we can use this November to start our “day one” of integrating tobacco cessation more fully into our behavioral health programs and to use the resources available to seize the day toward improved treatment outcomes with tobacco-free recovery.

Author's Note

Cele Fichter-DeSando, MPM (She, Her) is a consultant and trainer in substance use and gambling prevention and tobacco prevention and control. Cele has a Master’s degree in Public Management from Carnegie Mellon University and more than 35 years of experience in the management, training, and implementation of research-based prevention programs in Pittsburgh Pennsylvania. In 2020, Cele started a certified woman-owned business, CFD Consulting LLC, and has provided consulting for numerous organizations including Tobacco-Free Allegheny, the PTTC Network, and the Danya Institute Central East ATTC. She is passionate about providing resources, materials, and practical applications for evidenced-based prevention programs and prevention science to prevention practitioners.

Cele Fichter-DeSando, MPM
CFD Consulting, LLC
[email protected]



American Academy of Family Physicians. (AAFP), 2021.

American College of Academic Addiction Medicine (ACAAM) 2021.

American Cancer Society, 2021.

American Lung Association, 2021.

Centers for Disease Control and Prevention. Tobacco Cessation Change Package. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2020.

Centers for Disease Control (CDC) 2021.

Druss, B. G., Zhao, L., Von Esenwein, S., Morrato, E. H., & Marcus, S. C. (2011). Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical care, 49(6), 599–604.

Hall, S. M., & Prochaska, J. J. (2009). Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annual review of clinical psychology, 5, 409–431.

Marynak K, VanFrank B, Tetlow S, et al. Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:519–523. DOI:

National Institute on Drug Abuse (NIDA) 2021.

NIDA. 2018, May 31. Cigarette Smoking Increases the Likelihood of Drug Use Relapse. Retrieved from on 2021, July 8

Smoking Cessation Leadership Center (SCLC) at the University of California, San Francisco, the National Center of Excellence for Tobacco-Free Recovery (CTFR).

Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P et al. Change in mental health after smoking cessation: systematic review and meta-analysis BMJ 2014; 348 :g1151 doi:10.1136/bmj.g1151

Substance Abuse Mental Health Services Administration (SAMHSA) 2021.

Treating Tobacco Use and Dependence: 2008 Update. Content last reviewed February 2020. Agency for Healthcare Research and Quality, Rockville, MD.

Tsoh, J. Y., Chi, F. W., Mertens, J. R., & Weisner, C. M. (2011). Stopping smoking during first year of substance use treatment predicted 9-year alcohol and drug treatment outcomes. Drug and alcohol dependence, 114(2-3), 110–118.

University of California, San Francisco, 2021. Rx for Change

Weinberger AH, Delnevo CD, Wyka K, Gbedemah M, Lee J, Copeland J, Goodwin RD. Cannabis Use Is Associated With Increased Risk of Cigarette Smoking Initiation, Persistence, and Relapse Among Adults in the United States. Nicotine Tob Res. 2020 Jul 16;22(8):1404-1408. doi: 10.1093/ntr/ntz085. PMID: 31112595; PMCID: PMC7364845.

Weinberger AH, Platt J, Esan H, Galea S, Erlich D, Goodwin RD. Cigarette Smoking Is Associated With Increased Risk of Substance Use Disorder Relapse: A Nationally Representative, Prospective Longitudinal Investigation. J Clin Psychiatry. 2017 Feb;78(2):e152-e160. doi: 10.4088/JCP.15m10062. PMID: 28234432; PMCID: PMC5800400.

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