Smoking CeSSation treatment at SubStanCe abuSe rehabilitation ProgramS

Cigarette smoking is common among persons with drug and alcohol use disorders, with prevalence rates of 80-90% among patients in sub- stance use disorder treatment programs. Such concurrent smoking may produce adverse behavioral and medical problems, and is associated with greater levels of substance use disorder. Behavioral studies indicate that the act of cigarette smoking serves as a cue for drug and alcohol craving, and the active ingredient of cigarettes, nicotine, serves as a primer for drug and alcohol abuse (Sees and Clarke, 1993; Reid et al., 1998). More critically, longitudinal studies have found tobacco use to be the number one cause of preventable death in the United States, and also the single highest contributor to mortality in patients treated for alcoholism (Hurt et al., 1996). Nicotine is a highly addictive substance that meets all of the criteria for drug dependence, and cigarette smoking is an especially effective method for the delivery of nicotine, producing peak brain levels within 15-20 seconds. This rapid drug delivery is one of a number of common properties that cigarette smok- ing shares with hazardous drug and alcohol use, such as the ability to activate the dopamine system in the reward circuitry of the brain. Besides its addictive properties, cigarette smoking is legal and socially acceptable in many settings, giving it greater availability than other drugs of abuse. With these factors in mind, it is not surprising that cigarette smoking is one of the most difficult addictions to beat, with quit and relapse rates no better than for alcohol or heroin (USDHHS, 1988). A comprehensive approach Treating nicotine addiction requires a comprehensive approach, similar to treating most other forms of drug dependence. Combined therapy, with both medication and counseling, is considered to be the opti- mal approach and numerous forms of medication and counseling are now available. Nicotine replacement, with either transdermal nicotine patches, nicotine gum, nicotine lozenges or nicotine inhalers, is perhaps the most common form of medication. Other medications include the antidepressant bupropion (Zyban®), and the recently approved nicotine receptor stabilizer varenicline (Chantix®). Counseling includes indi- vidual and group programs focused on mood management, relapse prevention, and cognitive behavioral management of craving and relapse, and can be obtained via primary care providers, specialized treat- ment programs, telephone quit lines, or even self-help internet sites and books. In the general population, smoking cessation quit rates range from 25-40% at the end of treatment. Despite the evidence that cigarette smoking has an adverse impact on the health and use patterns of drug and alcohol use dependent individuals, and the extensive array of treatment options available for smoking cessation, cigarette smoking and other forms of tobacco use have traditionally been ignored in substance use disorder treatment settings in the United States. Resistance to nicotine dependence treatment in these settings is multifaceted, based on fear of detrimental effects on substance use dis- order treatment outcomes, the belief that clients are not interested in quitting, a concern that program