|Home | About | Journals | Submit | Contact Us | Français|
Persons entering substance abuse treatment smoke at rates three to four times that of the general population, but programs providing substance abuse treatment rarely address comorbid nicotine addiction. With California’s recent adoption of a regulation requiring alcohol and other drug (AOD) counselors to be certified, this study explored the degree to which nicotine addiction education was required or recommended to obtain certification by examining pertinent documentation and Web sites. Findings reveal two main points. First, the text of the California AOD Counselor Certification regulation and supporting documents make no mention of cigarettes, nicotine, smoking, or tobacco, and thus do not mandate or recommend they be addressed in the counselor certification process. Second, although nicotine or tobacco were not mentioned in regulatory or supporting documents, four of the 10 certifying organizations mentioned nicotine at least once in handbooks, program books, continuing education topics, or other materials available online. One certifying organization offered specialization in smoking and nicotine addiction as separate tracks within its certification training program. While systematic inclusion of smoking and nicotine addiction in counselor training offers one strategy to address smoking in substance abuse treatment settings, these topics are not addressed in regulations or supporting documents governing the certification of California AOD counselors.
Persons enrolled in substance abuse treatment smoke at a higher rate than the general population (Lasser et al. 2000; Hughes 1995a, b). Smokers with co-occurring involvement in other substance abuse may be more heavily addicted to nicotine, and less successful in attempts to quit smoking, than are smokers without other co-occurring substance abuse (Hays et al. 1999; Burling et al. 1997; Bobo et al. 1987). At least two studies have suggested that smokers enrolling in substance abuse treatment are more likely to die of causes related to smoking than of causes related to other substance abuse (Hurt et al. 1996; Hser, McCarthy & Anglin 1994). Clinical practice guidelines note that smoking cessation intervention “could be conveniently delivered within the context of chemical dependence clinics,” and recommend that persons in substance abuse treatment be provided with such intervention (Fiore, Bailey & Cohen 2000: 100).
Despite these considerations, nicotine dependence is often overlooked in drug treatment programs (Fiore, Bailey & Cohen 2000). Some counselors believe that persons in treatment should avoid major life changes (like quitting smoking) during their first year of recovery (Prochaska, Delucchi & Hall 2004). Lack of resources to provide smoking cessation services, lack of reimbursement for nicotine-related counseling or for the cost of nicotine replacement therapy, and the view that smoking is a low priority in drug treatment are commonly reported barriers (Sussman 2002; Hahn, Warnick & Plemmons 1999; Burling et al. 1997; Sees & Clark 1993; Bobo 1989). Staff who smoke may be reluctant to address smoking with their clients (Bernstein & Stoduto 1999), less likely to encourage clients to quit smoking, and less likely to participate in discussions of treating nicotine dependence (Campbell, Krumenacker & Stark 1998; Bobo & Davis 1993).
Williams and Ziedonis (2004: 1076) observed that drug abuse treatment program staff “have had limited training in addressing tobacco and have limited knowledge about nicotine neurobiology.” If lack of awareness and limited training represent barriers to addressing nicotine dependence in drug treatment settings, then workforce education may encourage smoking cessation intervention. Indeed, clinical practice guidelines regarding tobacco use and dependence recommend that “All clinicians and clinicians-in-training should be trained in effective strategies to assist tobacco users willing to make a quit attempt…” (Fiore, Bailey & Cohen 2000: 109).
Inclusion of nicotine education in certification standards is one way to influence the assessment and intervention for nicotine dependence in drug treatment programs. State and national bodies ensure a qualified counselor workforce through certification, based on completion of a minimum level of education and field experience (Mustaine, West & Wyrick 2003). In one national study of the substance abuse treatment workforce 72% of respondents were certified drug and alcohol counselors (Mulvey, Hubbard & Hayashi 2003), suggesting that certification requirements can potentially inform practice for a majority of this workforce.
In April 2005, California’s Department of Alcohol and Drug Programs (ADP) followed 37 other states in adopting a regulation requiring certification of alcohol and drug counselors (CA ADP 2006b, c). Ten organizations, selected on the basis of an established relationship with ADP and other considerations, were approved to grant alcohol and other drug (AOD) certification (CA ADP 2005b). Counselor certification requirements stated in the regulation apply to all counselors working in substance abuse treatment programs licensed or certified by the State of California. This treatment system includes over 2,380 treatment programs and nearly a quarter of a million admissions each year (CA ADP 2005a, b). The Bureau of Labor Statistics (2006) reported that there were 9,120 substance abuse and behavior disorder counselors in California.
While certification alone does not guarantee any specific practice will occur, inclusion of nicotine dependence in counselor certification requirements may suggest how California views this issue in the context of other addiction treatment. The degree to which certifying organizations do or do not include nicotine dependence in their informational materials may inform policy makers about how to better address nicotine dependence in drug abuse treatment systems. If certification requirements or practices of certifying organizations do not address nicotine dependence, then other strategies may be needed to ensure that counselors are adequately trained to address nicotine dependence. On the other hand, if certification requirements do address nicotine dependence, then it may be helpful to focus efforts on how those requirements are implemented by certifying organizations. The present study examines the degree to which information about nicotine—its effects, health risks, and benefits of simultaneous treatment of nicotine as an addictive substance—are included in materials that shape the education content necessary to obtain certification in California.
To understand the California requirements for certification, two categories of materials were reviewed: (1) the Counselor Certification Regulations and supporting documents, and (2) information on the 10 organizations approved to provide counselor certification (see Table 1). Publicly available online materials were reviewed as a reflection of each organization’s public position on addiction treatment.
The full, Web-based text of the regulations and the national and state-level materials mentioned in the regulations were examined to identify requirements and guidelines. Supporting documentation on the Counselor Certification Web pages was also reviewed.
The California regulations identify 10 organizations that are approved to confer certification to AOD counselors; the Web sites and online materials of these organizations were reviewed. Certifying organizations either provide their own classroom education or offer education through educational providers such as post-secondary institutions.
This study was conducted from January through November 2006. Software tools included Web browsers (Mozilla Firefox Version 1.5 and Microsoft Internet Explorer Version 6.0) and Adobe Reader Version 7.0. The method involved counting mentions of key terms in the documents reviewed. Mentions of nicotine and its synonyms (smoking, tobacco) were searched for either by sight reading or electronically by using the Find, Find in this Page, and Search functions in the software tools; once found, the mentions were tabulated. Even if nicotine and related terms are not mentioned in the materials as a required topic, repeated mentions of it would imply that it is a topic of importance. For comparison, we tabulated mentions of heroin, methamphetamine, and marijuana, which are common, illicit substances of abuse in California (CA ADP 2005b).
According to the regulation, the minimum training requirements for certification included: formal classroom education in subjects concerning provision of services to special populations such as aging individuals and individuals with co-occurring disorders (e.g., alcoholism and mental illness); ethics; communicable diseases (e.g., tuberculosis and HIV disease); and prevention of sexual harassment. Addictive substances were consistently referred to as “alcohol and drugs,” “alcohol and other drugs,” or “substances.” Individual drugs were not named and the regulation did not include guidance on training related to nicotine.
The regulation referred to CSAT’s Technical Assistance Publication Series 21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice to further define content of required training (CSAT 2006). This publication, commonly referred to as TAP 21, described a general set of required competencies but did not mention individual drugs of abuse or specific treatment approaches. The other four documents listed on the Counselor Certification Regulations Web page, such as Statement of Reasons and the Regulations Questions & Answers, (ADP2006 b, d) did not mention nicotine or any other specific drugs.
The ADP Fact Sheets Web page listed over 60 documents (CA ADP 2006a). One fact sheet entitled Facts and Figures on Alcohol and Other Drugs mentioned alcohol, heroin, methamphetamine, marijuana/hashish, and other drugs by name, but did not mention nicotine or tobacco. Fact sheets were organized under categories such as Alcohol and Other Drug Facts, Driving under the Influence, Perinatal Substance Abuse Topics, and 15 others, but no categories were devoted to nicotine. Titles of individual fact sheets included Alcohol Use, Facts and Figures on Cocaine, Drinking-Related Behaviors, and Facts and Figures on Methamphetamine. One fact sheet addressed the sale of tobacco to minors. Apart from this, there were no mentions of cigarettes, nicotine, smoking, or tobacco in the titles of fact sheets. A review of six fact sheets in the Alcohol and Other Drug Facts category revealed no mentions of nicotine and its synonyms.
In a review of the websites of the 10 certifying organizations, none mentioned nicotine directly in their organization description, one offered certification tracks specializing in smoking cessation intervention, two offered links to detailed handbooks that covered smoking and nicotine, and three mentioned nicotine-related classes for continuing education units. Overall, the search found mention of nicotine or its synonyms among website material for four of the 10 certifying organizations.
The recent AOD counselor certification regulations in California were intended to standardize the education, experience, conduct, and complaint investigation for AOD counselors. Because nicotine addiction is prevalent among those with other substance abuse and dependence, we used the enactment of the regulation as an occasion to evaluate the degree to which nicotine addiction is addressed in the California counselor certification process.
Our findings reveal two main points. First, the text of the California AOD Counselor Certification regulations and supporting documents make no mention of cigarettes, nicotine, smoking, or tobacco, and thus do not mandate or recommend they be addressed in the counselor certification process. Nicotine and tobacco are not unique in this regard, as most other drugs excluding alcohol are also not specifically mentioned in these documents. Fact sheets posted on the California ADP Web site, however, distinguish among alcohol, cocaine, and methamphetamine, but mention tobacco only in the context of sales to minors and not as a target of treatment or intervention. Second, although nicotine or tobacco were not mentioned in regulatory or supporting documents, four of the 10 certifying organizations mentioned nicotine or its synonyms at least once in handbooks, program books, continuing education topics, or other materials. One organization offered specialization in smoking and nicotine addiction as separate tracks within its certification training program.
Smoking continues to be the leading preventable cause of death in the U.S., the prevalence of smoking is elevated among persons entering drug abuse treatment, and many treatment programs do not address smoking even in the presence of practice guidelines encouraging them to do so (Fuller et al. 2007; Fiore, Bailey & Cohen 2000; Sees & Clark 1993). Consequently, addressing smoking in substance abuse treatment systems represents a public health concern, a health disparities concern, and a clinical best practice concern. Based on this review of the California counselor certification regulation and related documents, we conclude that smoking and nicotine addiction are not adequately addressed in regulations governing the training of California AOD counselors. Systematic inclusion of training on smoking and nicotine addiction in counselor training offers one strategy to better address smoking in drug treatment settings, and collaboration between state departments of alcohol and drug treatment and national and professional organizations can support in the development of policy guidelines in this area (Walsh et al. 2005; Hahn, Warnick & Plemmons 1999).
The work reported here concerns AOD counselor certification in California only, and may not generalize to certification in other states. It is limited by reliance on Web-based materials, which represent publicly available information through which counselors would investigate the certification process and education requirements. With regard to certifying organizations, our methods may result in a distorted view of how well these same topics are covered. A more comprehensive review of program brochures, handbooks in hardcopy, or interviews with representatives of certifying organizations may have resulted in a different perspective of the degree to which nicotine is addressed by certifying organizations. Further, study procedures did not attempt to correct for variation in the quantity of information posted on individual Web sites, which ranged from less than 10 pages to multi-tier site structures and downloadable handbooks, and nicotine or tobacco mentions may increase commensurate with the amount of information posted. Finally, we cannot comment on the degree to which smoking and nicotine addiction are or are not included in actual counselor training in California. Among the 10 certifying organizations, some provide training directly while others accredit training programs offered in California college and university settings; there are approximately 70 such training programs throughout the state. Systematic study of curricula in each of these programs would be needed to further assess the degree to which nicotine addiction is, or is not, incorporated into counselor training.
These limitations notwithstanding, the nationally promulgated Addiction Counselor Competencies (in TAP 21), on which the California regulation bases its certification training content, the language of the regulations themselves, and associated documents on the state ADP Web site were silent with regard to nicotine, smoking, and tobacco. Publicly available and accessible materials describing certification agencies and approved training programs did mention these topics, but infrequently. Given the comorbid nature of smoking and nicotine addiction with other substance abuse, and the relevance for public health in general as well as the individual health of persons involved in drug abuse treatment systems, we recommend that training in assessment and intervention for nicotine addiction be included in AOD counselor certification and training requirements in California.
†This work was supported by the National Institute on Drug Abuse (R01 DA-020705), by the California-Arizona research node of the NIDA Clinical Trials Network (U10 DA-015815), and by the NIDA San Francisco Treatment Research Center (P50 DA-009253).