For decades, it has been common knowledge that smoking cigarettes is bad for your overall health.

But only in recent years have the strategies to approach helping people quit truly evolved to address the complexities of achieving lasting smoking cessation.

“That’s the difference between our program and a lot of other programs,” said Lisabeth Bennett, clinical director of tobacco cessation services at CODAC Behavioral Healthcare, from their Cranston office. “It’s not designed for the people who are like, ‘I’m ready to quit right now, cold turkey, and ready to make that change.’ We’re more about making gradual change at your own pace given your own particular medical history and your circumstances and your goals.”

Founded in 1971, CODAC is Rhode Island’s oldest, largest and most comprehensive outpatient behavioral healthcare agency – affiliated under the state Department of Health – that deals not only with treating and guiding people who want to kick their addiction to nicotine, but also train individuals to become tobacco treatment specialists so they may assist people outside of their direct umbrella. There are seven CODAC locations, with another coming soon to Pawtucket.

The agency specializes in many different behavioral healthcare issues – from its heralded opioid addiction treatment (all of its locations were named Centers of Excellence for opioid treatment in 2016) to gambling problems – but the tobacco program stands out as a prime example of the difference an individualized approach to healthcare can make for the people they serve.

Quitting comfortably

CODAC does not set hard dates for its clients to quit smoking for good, nor does it force anybody into medication-assisted treatment or a “cold turkey” scenario, as Bennett mentioned. Instead, their cessation specialists focus on the unique situation of the person in front of them.

“Our program is individualized and person-centered,” said Kristina Micheli, clinical supervisor for the smoking cessation program. “It’s really a supportive program, taking into consideration what exactly the person wants and the fact that the person is a key player in their quit plan and treatment plan.”

Patients – CODAC received about 300 referrals last year – have a variety of services made available to them, including one-on-one counseling, group counseling and a range of pharmaceutical-assisted approaches to steer them toward their goal. That goal may be simply to smoke less for now and quit later down the line, or to start a process to quit entirely right away.

Micheli and Bennett pointed to the words on an information brochure, “quitting comfortably,” as the key to the program’s efficacy.

Quitting comfortably means advancing beyond the strategies of the past, which often invoked the use of willpower to overcome the physical and emotional toll that quitting smoking takes on a person. Although physical symptoms to nicotine addiction usually subside within a few days of stopping, the mental and behavioral challenges of quitting often cause people to relapse – as many as 10 times on average, or more, depending on the person.

For this reason, CODAC believes implementing a strategy that allows more freedom leads to better results, as slowly weaning cigarettes from one’s life is a more realistic approach than crushing a pack and never picking up one again.

“This whole idea you’re going to have willpower the whole time is crazy. We know that from studying brain science research. Willpower is a timeline that you can only hold onto for so long. We help set up a scenario where you’re comfortable all the way along so you don’t have to use willpower,” Bennett said. “You can find a level that helps you taper down, and that creates the physical comfort – so the physical and emotional withdrawal symptoms are not something you have to deal with, they kind of just dissipate on their own – and you’re able to work on the behavioral part.”

Along with the behavioral support, Bennett spoke about how science regarding medically-assisted treatments – things like the patch, lozenges or even prescription medication – has gotten much more advanced in recent years and, similar to the opioid epidemic, has shown to be an incredibly effective route to get people to break their cycle of dependence. CODAC provides people with options and information about which implement is right for them (sometimes multiple methods are best) and helps them access the products through working with their insurance company.

“People in the old days, if they wanted to stop smoking and switched to a thing like the patch, it was an all-or-nothing proposition. You were told you couldn’t smoke while on the patch,” Bennett said. “That all or nothing proposition didn’t work for everybody … and those are the people that we’re seeing today.”

Bennett said that while the center doesn’t endorse the use of e-cigarettes and vaping products in lieu of smoking – there is no proven “safe” alternative to cigarettes, she says – if a client feels that such an implement can help them toward their goal of total cessation, CODAC will not prevent them from doing so. Providing freedom to let people quit in their own way is the overarching theme, even if that means taking small steps one at a time.

“It gives you the freedom, it buys you the flexibility and the comfort in order to make those behavioral changes and build a new normal,” Bennett said. “You will suddenly realize that you’re not smoking in the morning and you’re not smoking on break and you’re not smoking after dinner and you will suddenly have this new normal, just like everybody who doesn’t smoke has.”

Funding loss limits, but doesn’t end mission

While she didn’t provide specific numbers, Bennett spoke briefly about how CODAC is losing some of its funding from the state as of this March, which will force the agency to “limit their scope” to operating within their facilities, rather than sending staff out to other places in the state as they had been doing.

“We’ve had the ability to offer treatment to people who are uninsured, to people at Crossroads and people that are homeless,” she said. “We’ve been able to reach these people in more vulnerable populations because of that funding.”

Bennett spoke of the four “priority populations” that CODAC strives to support in their smoking cessation program – patients who suffer from other forms of substance abuse, patients with mental health disorders, people in rural populations and the homeless – all of which are more susceptible to starting smoking and smoking throughout their lives.

While CODAC will be more limited in how they can provide support to other organizations in Rhode Island following the funding loss – which Department of Health spokesman Joseph Wendelken said was due to a loss in federal funding that required “some reorganizing to continue supporting our Smoker’s Helpline” – Bennett said that this doesn’t mean CODAC’s tobacco cessation program is shutting down.

“We are very fortunate that CODAC, as an agency, has had a commitment to tobacco treatment way before it was cool to do so,” she said, adding that CODAC was one of the first agencies to become a completely smoke-free workplace in the nation in 2012. “The fact that we are going to have to narrow our scope outside of CODAC due to the funding changes is one thing, but within CODAC we are continuing that commitment to offer comprehensive tobacco treatment services at every location and also our commitment to increasing treatment capacity by continuing our training programs.”

Further, Bennett mentioned how Rhode Island is one of the states in the country that gives tobacco treatment specialists the ability to bill insurance companies for the treatment they provide.

“This is something that is really under-utilized,” she said. “Why doesn’t every primary care practice have people specially trained in doing that?”

Funding for smoking cessation in the state is a topic of importance to health advocacy groups such as the American Cancer Society Cancer Action Network (ACS CAN), which laments the fact that only around $390,000 is dedicated to smoking cessation in the state budget, despite the Centers for Disease Control recommending the state spend $12.8 million. For context, the state earns nearly $200 million annually from cigarette sales taxes and money from a federal Master Settlement Agreement. In 2011, state funding for tobacco cessation was at $732,000.

Wendelken mentioned in an email that smoking rates in Rhode Island continue to decline and that the youth smoking rates in Rhode Island are among the lowest in the country, and that 2009 legislation enabled Rhode Island to establish statewide insurance coverage for tobacco cessation resources, including for people on Medicare.

“A lot of what we would be providing as a state health department is already provided by public and private insurers,” he wrote.