Elisabeth A. Stelson, MSW, MPH, Harvard T.H. Chan School of Public Health; Lauren Sabbath, MSW, Clearhaven Recovery Center; Glorian Sorensen, PhD, MPH, Harvard T.H. Chan School of Public Health; Erika Sabbath, ScD, MSc, Boston College School of Social Work
To assess the relationship between personal addiction history among addiction treatment providers working in residential settings, occupational stress, and smoking from the perspectives of this workforce.
The rate of smoking in the US population has declined by two thirds over the past 50 years. However, people who are in addiction recovery continue to have higher rates of smoking than the general population. Common myths in the addiction recovery community suggest that smoking cessation may threaten sobriety and that people in recovery should address one addiction at a time to avoid relapse of “harder” substances. Studies have found that people who smoke and have a substance use disorder are more likely to die from smoking-related causes than substance-related causes. A large percent-if not majority-of people working as addiction treatment professionals (ATPs) are in recovery from addiction themselves, and rates of smoking in this workforce may be as high as 45%. Providing addiction treatment is stressful and emotionally challenging work, especially in residential settings. Over the past 30 years, there has been increased attention to the effectiveness of integrating smoking cessation within addiction treatment for clients, while smoking in the ATP workforce remains largely overlooked.
ATPs working in nonprofit recovery homes in Massachusetts were purposively recruited according to organizational role and geography to participate in semi-structured interviews or focus groups. Participants included executive leadership, middle management, and direct service providers (counselors, case managers, residential assistants, peer specialists). All interviews and focus groups were audio recorded and transcribed verbatim. Data collection has been completed, and analysis is currently underway. The code book was developed through an open-coding process with additional a-priori codes from the research team’s conceptual model of working conditions, worker health, and turnover. Coding is facilitated using NVivo 12, and 30% of transcripts will be double coded to ensure coding consistency. Interrater reliability will be calculated using the Kappa statistic, and an immersion-crystallization approach will be used to facilitate thematic analysis.
ATPs (N=49) from 14 nonprofit recovery homes participated in 33 interviews and 4 focus groups. Preliminary analysis indicates that many of these participants self-disclosed as being in recovery, and this personal experience encouraged participants to work in this field. Participants described workplace stressors, such as listening to patients’ trauma histories, frequent need for de-escalation, overdose reversals and deaths, limited private work spaces, substantial paperwork, and overnight shift work. Many participants described how work responsibilities crept into their home-lives whether through formal responsibilities, such as being on-call, or concern about patients. Many participants described high rates of turnover at their organizations, which often increased their work responsibilities. When asked about coping behaviors to manage stress, participants often described how they or their coworkers were smokers. Some participants described how smoke breaks were a reprieve from the stressful work environment and lack of quiet space. Others described how they started smoking during their addiction and never quit. Some participants referenced patients smoking, indicating frequent exposure to the behavior. Of the 14 different organizations represented in this study, only one organization reported having a smoking cessation incentive for its workers. This organization provided extra vacation days for nonsmokers and those who quit. Participants from this organization described the intervention as beneficial since many people needed vacation days and mental health days to sustain their ability to continue to do this challenging work. Participants at this organization described the organization as “the last place I’ll ever work” and indicated that staff turnover rates were low.
This formative research indicates that smoking among ATPs may remain a more common coping mechanism than in other workforces. Many ATPs reported being in recovery themselves, and individuals experiencing or recovering from addiction tend to have higher rates of smoking. Working in residential addiction treatment settings can be challenging and stressful, which may encourage smoking as a coping mechanism and may discourage quit attempts. Participants described high staff turnover and a need for time off. ATPs may benefit from more vacation and mental health days to manage occupational stressors and sustain their work. Smoking cessation policies that rewards quitting with vacation days may be effective to both improve the health of the workforce and also decrease stress and turnover in addiction treatment settings.
Limitations: This formative research aims to understand the relationship between working conditions, ATP health, turnover, and client care. Findings on smoking emerged from data analysis, but was not the specific focus on the study. Findings may not be generalizable, but may be transferable to ATPs in other residential settings.
The addiction treatment workforce experiences substantial occupational stressors, and these stressors-coupled with workers’ personal addiction history-may contribute to greater smoking prevalence and high staff turnover. Future intervention research should explore the effectiveness of vacation day incentives to encourage smoking cessation and reduce turnover.