Allowing inpatients who are at chemical dependence treatment facilities to go outside to smoke is an outdated and indefensible practice -- yet it is still the norm across the country, Dr. Elizabeth B. Stuyt said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

Not only is this practice psysically unhealthy in so many ways, it also undercuts the effectiveness of the patient's treatment program, according to Dr. Stuyt, who is medical director of the Circle Program, a 90-day inpatient treatment program based on cognitive-behavioral therapy for dual diagnosis patients at the Colorado Mental Health Institute at Pueblo.

"Since the 1970s, we've evolved to an understanding that we have to treat mental illness at the same time as substance abuse problems, and I truly believe we also have to treat tobacco dependence at the same time." she said.

"I think one reason substance abuse treatment results have been so dismal is that nicotine is [the] one drug we've totally missed that we're not treating. We're allowing people to continue to smoke avidly" she said.

Positron emission tomography data have shown that cocaine, amphetamine, alcohol, and nicotine affect the same area of the brain, the psychiatrist said.

A cornerstone of cognitive-behavioral therepy is the careful titration of exposure and response prevention. In the setting of substance abuse, this involves group sessions aimed at fanning drug cravings in a controlled environment to teach patients how to manage their cravings without getting high.

Allowing patients to go outside for a smoke after such a session destroys its therapeutic value.

In a prospective study conducted several years ago in Lubbock, Texas, Dr. Stuyt showd that 1 year recovery rates after inpatient treatment for substance abuse were significantly better in nonsmokers than in smokers. particularly if their drug of abuse was alcohol, narcotics, or another dedative (Am. J. Addict. 6[2]:159-67, 1997).

When challenged by Dr. Stuyt for their policies of letting patients go outside to smoke, program directors at some of the country's best-know private substance abuse treatment facilities cited the financial bottom line.

In other words, they are concerned that many alcohol and drug-abusing patients will balk at a tobacco-free inpatient treatment center.

"Guess what? That doesn't happen," according to Dr. Stuyt. "I did this at a private hospital in Texas; we had no decrease in census. Here at the Colorado state hospital, I have a 4-month waiting list for the Circle Program. I haven't had a single person who's refused to come because they cannot smoke."

Change may be starting to take place. For example, Dr. Stuyt recently consulted with the program directors of all state-run chemical dependence units in New Jersey and Massachusetts. And administrators in both of those states are considering having those clinics go tobacco-free.

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