TOBACCO CESSATION WITH PATIENTS RECOVERING FROM ALCOHOL AND OTHER SUBSTANCE ABUSE

Smoking has been identified as the leading cause of premature morbidity and mortality in this country for some time. The vast majority of the general public in the United States and all leading health care organizations in the world acknowledge this fact and stress the importance of cessation for all smokers. Despite this fact, certain segments of the population have been excluded from messages regarding the importance of smoking cessation. One of the largest of these groups are individuals in recovery from alcohol and drug abuse. According to the first report from the National Longitudinal Alcohol Epidemiologic Survey (NLAES) on data collected in 1992, there were 13,760,000 adults who met the DSM-IV diagnostic criteria for alcohol dependence or abuse in the United States.15 This is 7.4% of all persons over the age of 18. These rates were higher among men than women and highest in the youngest age cohort (18–29 years). Based on generalizations from previous research, it is also known that anywhere from 66%40 to 97%48 ; 55 of these individuals are smokers, a smoking prevalence 2.5 to 4 times higher than that in the general population.14 They are generally heavier smokers (over a pack a day)19; 21 ; 40 and about 50% think that it would be as hard to much harder to quit smoking as to stop their alcohol addiction.28 ; 40 These generalizations about smoking also apply to the 13 million individuals52 who use illicit drugs. Use of illicit drugs generally is preceded by use of cigarettes and alcohol before,16 and levels of tobacco and alcohol use have been found to be higher in persons who progressed to illicit drug use.51 In a study comparing the smoking rates of inpatients being treated for alcohol abuse only, illicit drug abuse only, or mixed alcohol and drug abuse, Burling and Ziff8 found higher smoking rates in the mixed abuse group than the alcohol abuse only or drug abuse only groups. The alcohol abuse group, however, smoked significantly more cigarettes a day and had greater nicotine dependence as measured by a tolerance questionnaire than the other two groups. In addition to the standard health risks, there is evidence of special health risks associated with smoking for the alcohol- and drug-abusing population. Excessive alcohol use and smoking are independent, additive risk factors for cardiovascular disease, respiratory disease, and certain types of cancer.37 Rosengren et al47 reported a relative risk of mortality over 12 years of 11.0 in smoking nonalcoholics, 17.0 in nonsmoking alcoholics, and 26.4 in smoking alcoholics compared with nonsmoking nonalcoholics. A synergistic effect between alcohol and smoking has been implicated in the increased risk for oral, pharyngeal and laryngeal cancers seen in alcoholic smokers.2; 11 ; 13 Hinds et al17 found the relative risk of developing laryngeal cancer in heavy smokers was 2.1, in heavy drinkers it was 2.2, and in individuals who both smoke and drank heavily it was 8.1. In terms of other drug use, there may be an increased risk for lung cancer among those who smoke both tobacco and marijuana because of the potential carcinogenic properties of marijuana smoke.23 ; 38 The combined use of cigarettes and cocaine has been shown to substantially increase the metabolic requirement of the heart while simultaneously decreasing the blood supply, thereby increasing the potential for a cardiac event.33 ; 35 In a more recent study, Hurt et al22 looked at the impact of tobacco and alcohol-related deaths on overall mortality following inpatient treatment for alcoholism and other non-nicotine drugs of dependence. Of the 214 deaths in the identified population (845 patients in inpatient treatment for addiction between 1972 and 1983), 51% were from tobacco-related causes, and 34% were from alcohol-related causes. Cumulative mortality was greater than expected at 20 years (48% versus 18.5%). Considering the greater number of tobacco-related causes of death, the authors22 concluded that “nicotine dependence treatment is imperative in such high-risk patients.” Until very recently, the chemical dependency treatment community strongly discouraged physicians and others from providing smoking cessation advice and counseling to patients with alcohol or other substance abuse problems. Treatment lore held that the recovering individual's hold on sobriety was tenuous at best, and smoking cessation would seriously endanger this sobriety by increasing the stress experienced in the person's life.4 This view held whether the individual was newly entering treatment or had been abstinent for 15 years. A correlative belief was that most individuals in recovery would not be interested in attempting to quit because of the potential threat to their abstinence. Whether due to these beliefs or other factors, the fact remains that the significant public health campaign of the past 40 years to reduce smoking in this country passed by this population. A number of studies in the last 15 years have given us important information on the effect of smoking cessation on stress levels.10; 41 ; 42 Parrot41 reviewed four studies looking at the relationship between cigarette smoking and stress. He noted that the stress modulation effect of smoking represented primarily the relief of adverse mood associated with the onset of nicotine withdrawal symptoms, rather than attainment of a beneficial mood by the individual. Those smokers who smoked mainly for a calming or relaxing effect showed above average stress levels before smoking but only average stress levels after smoking. Previous longitudinal trials10 ; 42 also have shown that self-perceived stress was significantly reduced after successful cessation, possibly because daily nicotine withdrawal-induced fluctuations in physiologic state and mood had been removed as a source of stress. To the extent that this model also applies to this subset of smokers, it is speculated that the act of quitting smoking will produce increased stress for the period of time necessary for nicotine clearance. This should subside, however, and be replaced by a lower daily stress level than that experienced before cessation, a pattern similar to that seen in any successful withdrawal from an addictive substance. The results of studies on the effect of smoking cessation on sobriety3; 5; 7; 21; 25; 31 ; 32 and attitudes toward smoking cessation among alcohol- and drug-abuse patients28; 36; 40 ; 49 report a number of similar findings. First, smoking cessation does not appear to adversely affect sobriety outcomes in individuals recovering from alcohol or drug problems. Second, the majority of these individuals would like to quit smoking and almost half have made attempts to quit in the past. Third, most would prefer to do it after completion of their current recovery program. A substantial number of those patients surveyed, however, indicated that they would be willing to consider smoking cessation at the same time that they were in treatment for their other addiction. Further research is needed, however, to ascertain the most effective timing and techniques for tobacco cessation in this populations. Recently, results of a randomized community intervention trial that randomly assigned 12 residential alcohol treatment centers (the “communities”) to a minimal tobacco smoking cessation intervention or usual care condition were reported.5 After 1 year of follow-up of 575 recovering alcoholic patients, significantly lower drinking relapse rates among patients encouraged to quit smoking (P < .01) were observed; however, the effect of the minimal intervention on tobacco quit rates was not statistically significant. The treatment community has noted these results. An increasing number of programs are going smoke-free either voluntarily or because of JCAHO mandates.19 In 1993, an entire journal for professionals in the field of chemical dependency was devoted to articles outlining the reasons for addressing nicotine dependency during chemical dependency treatment and highlighting programs that already had started in the process.9; 12; 18; 24; 26; 27 ; 43 In answer to the question, “why do it?,” Hoffman and Slade18 gave eight reasons: smoking is an important cause of preventable death in the chemically dependent population; failing to address smoking dependence contradicts and undermines the language of treatment for other addictions; many patients in treatment want to work on their smoking addiction at the same time; treatment for nicotine dependence alone is usually not covered by insurance; second-hand smoke is a health hazard for non-smokers; some ex-smokers relapse to smoking during treatment for other chemical dependencies because of the high prevalence of smoking in treatment programs; it is against most state laws for adolescents under the age of 18 to obtain cigarettes; and smoking is a cue for drug and alcohol use and could be a stimulus to relapse. The research findings to date suggest that physicians should counsel their patients who have a history of alcohol or drug abuse problems to consider quitting smoking also. In this article, a model for a brief smoking cessation intervention that was developed for the community intervention trial described above is described.5 This model is readily usable within the standard 10 minute clinic visit. The model includes an algorithm for determining patients' stage of readiness to change their smoking behavior,45 counseling strategies that can be used at each stage,44 and an interviewing technique than can enhance patients' motivation for change.33 This model follows the clinical practice guideline for smoking cessation developed under the auspices of the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services.52