Co-quitting nicotine & alcohol: myth vs. fact

John (Gold)
John (Gold)

8:20 PM - Mar 26, 2007 #1

Smoking Cessation and Alcohol Abstinence:
What Do the Data Tell Us?
Suzy Bird Gulliver, Ph.D.; Barbara W. Kamholz, Ph.D.; and Amy W. Helstrom, Ph.D.
Departments of Psychiatry and Psychology at Boston University, Boston, Massachusetts.
Cigarette smoking and nicotine dependence commonly co-occur with alcohol dependence. However, treatment for tobacco dependence is not routinely included in alcohol treatment programs, largely because of concerns that addressing both addictions concurrently would be too difficult for patients and would adversely affect recovery from alcoholism. To the contrary, research shows that smoking cessation does not disrupt alcohol abstinence and may actually enhance the likelihood of longer-term sobriety. Smokers in alcohol treatment or recovery face particular challenges regarding smoking cessation. Researchers and clinicians should take these circumstances into account when determining how best to treat these patients' tobacco dependence.
Cigarette smoking and alcohol dependence co-occur at high rates. Research indicates that approximately 80 percent of people with alcoholism smoke cigarettes and that most of these smokers are nicotine dependent (Hughes 1996). Conversely, smokers are at two to three times greater risk for alcohol dependence than nonsmokers (Breslau 1995).
Despite the fact that 60 to 75 percent of patients in alcoholism treatment are tobacco dependent and about 40 to 50 percent are heavy smokers (Hughes 1995), treatment for tobacco dependence is not routinely included in alcohol treatment programs. Smoking cessation treatment (as well as bans on smoking) during the course of treatment for alcohol dependence has been avoided largely out of concern that concurrently addressing both addictions (or restricting smoking during treatment for alcoholism) poses too great a difficulty for the patient and would adversely affect recovery from alcoholism. Such concerns are apparent both in the United States and around the world (e.g., Walsh et al. 2005; Zullino et al. 2003). Myths surrounding concurrent treatment for smoking and alcoholism also include the ideas that smoking is a benign problem relative to alcoholism, that patients with comorbid alcoholism have either no interest or no ability to quit smoking, and that patients will relapse to alcohol if they quit smoking. This article summarizes the scientific findings that address these issues and provides evidence-based responses to common concerns about smoking cessation during alcoholism treatment.
Myth:Smoking is more benign than alcoholism. The short-term effects of alcoholism may appear more dangerous than those of cigarette smoking. However, mortality statistics suggest that more people with alcoholism die from smoking-related diseases than from alcohol-related diseases (Hurt et al. 1996). In addition, the greater prevalence of smoking in alcohol-dependent versus other populations exacerbates health risks (Bien and Burge 1990; York and Hirsch 1995). Researchers have demonstrated synergistic carcinogenic effects for dual substance dependence. For example, the relative risk of laryngeal cancer has been estimated at 2.1 in heavy smokers, 2.2 in heavy drinkers, and 8.1 in people who are both heavy drinkers and heavy smokers (Hinds et al. 1979).
Myth: Smokers with comorbid alcoholism have either no interest or no ability to quit smoking. It is interesting to note that although addiction treatment programs routinely address multiple substances of addiction (e.g., alcohol, marijuana, heroin, cocaine), tobacco is frequently the sole excluded substance. The scientific literature also frequently describes treatment of multiple nontobacco substances simultaneously, making it difficult to evaluate the impact of smoking cessation on alcoholism treatment per se (cf. Prochaska et al. 2004). Still, evidence contradicts the notion that smokers with comorbid alcoholism are not interested in quitting smoking and that addictions need to be treated one at a time (e.g., Kalman 1998).
Up to 80 percent of people in addiction treatment are interested in quitting smoking (cf. Prochaska et al. 2004). Consistent with this, Flach and Diener (2004) found that among dual users, approximately 75 percent wanted to quit both smoking and alcohol use (though the desire to quit alcohol use was rated as higher). Furthermore, many people entering treatment for alcoholism are willing to quit smoking (e.g., Saxon et al. 1997). In fact, one study found that 75 percent of substance-dependent inpatients accepted concurrent tobacco treatment (Seidner et al. 1996).
Inclusion of smoking as a target for intervention does not appear to reduce patients' commitment to broader addiction treatment. For example, incorporating smoking cessation treatment into inpatient addiction treatment centers has not substantially reduced long-term treatment completion (e.g., a minimal drop from 75 to 70 percent at one site) (Sharp et al. 2003). In addition, Monti and colleagues (1995) found that smoking rates actually decrease and the motivation to quit smoking increases following successful alcohol treatment.
Evidence suggests that a history of alcohol use difficulties may not impede a specific smoking cessation attempt, though it does seem to reduce the likelihood of quitting smoking during one's lifetime (Hughes and Kalman 2005). Research has yet to determine the extent to which smokers with current alcohol use difficulties are able to quit smoking. Though early research has suggested that quitting smoking would be more difficult for these patients (e.g., Hughes 1996), the answer is now less clear. The only two studies evaluating this issue separate from other substances of abuse and co-occurring psychiatric disorders yielded mixed findings and did not include more severe alcohol-dependent individuals (cf. Hughes and Kalman 2005). However, studies based on smokers in substance abuse treatment, and those in early recovery, suggest that cigarette abstinence is possible, though challenging (Martin et al. 1997; Prochaska et al. 2004).
Myth: Smoking cessation will impede successful alcohol use outcomes. Perhaps most important is the concern among treatment providers (and patients) that patients must choose between abstinence from cigarettes and abstinence from alcohol. In contrast to this concern, research suggests that treating tobacco dependence within broader addiction programs does not adversely influence recovery from alcoholism (or illicit substances). Although not universal (e.g., Joseph et al. 2004), the majority of findings indicate that smoking cessation efforts and smoking abstinence are unlikely to negatively influence alcohol use outcomes (cf. Fogg and Borody 2001). In a recent meta-analysis, Prochaska and colleagues (2004) evaluated the outcomes of smoking cessation interventions in 19 randomized controlled trials with people in addiction treatment or recovery. At the end of treatment, no differences in substance use outcomes were found between patients who engaged in smoking cessation treatment and those who did not. Looking at long-term abstinence from substances, an even more important finding emerged. That is, at long-term follow-up, participation in a smoking cessation intervention provided during substance abuse treatment was associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs. Consistent with these findings, data suggest that 1 year after treatment, smokers who participated in a substance abuse treatment program and initiated smoking cessation on their own were less likely to be diagnosed as alcohol dependent and had more days abstinent from alcohol and other substances than those who started or continued smoking during the follow-up period (Kohn et al. 2003). Thus, empirical evidence suggests that smoking cessation efforts may result in improved alcohol-related outcomes (even if those efforts do not yield substantial smoking abstinence).

The mechanisms of action responsible for the potential benefits of smoking cessation interventions provided during alcoholism treatment remain largely unexplored. However, possible explanatory factors may include greater clinical contact time, reduced exposure to substance use cues, relapse prevention and/or coping skills practice, increased mastery or self-efficacy, and broader healthy lifestyle choices (Prochaska et al. 2004). Self-initiated efforts to reduce smoking also may reflect increased patient motivation or lower levels of nicotine dependence (Karam-Hage et al. 2005).

Alcohol-dependent patients who quit smoking while in recovery from alcohol problems also do so without negative consequences to their alcohol or drug abstinence (Bien and Burge 1990; Bobo 1989; Hurt et al. 1993; Irving et al. 1994; Joseph et al. 2003; Sobell et al. 1990; Sullivan and Covey 2002). Data suggest that among alcohol- dependent smokers in early recovery, nicotine deprivation is not associated with an increased urge to drink. In addition, among people with significant alcohol abstinence, evidence suggests that smoking cessation does not increase the likelihood of relapse to alcohol use or increase alcohol-related cravings (Hughes et al. 2003). Data from Project MATCH, the largest alcoholism clinical trial published to date, indicates that alcohol-dependent smokers can quit smoking cigarettes without putting their sobriety at risk. In fact, those who quit smoking during their participation in Project MATCH drank less than those who did not quit smoking and significantly reduced their alcohol intake for the 6 months after quitting smoking (Friend and Pagano 2005). Similarly, Karam-Hage and colleagues (2005) studied smokers in alcohol treatment and found that participants who quit smoking on their own were more likely to report alcohol abstinence at 1- and 6-months' followup than participants who did not quit smoking (though this may be a function of lower levels of nicotine dependence).

Not only does the preponderance of evidence suggest that smoking cessation does not compromise alcohol abstinence, but multiple studies indirectly suggest that continued smoking may place alcohol-dependent smokers at risk for alcohol relapse (Taylor et al. 2000). These data are consistent with laboratory studies on cross-cue reactivity, which suggest that nicotine dependence and alcoholism may interact to increase drinking risk. For example, alcohol cues, such as the sight or smell of an alcoholic beverage, can increase smoking urges among smokers with alcohol use disorders (e.g., Cooney et al. 2003; Drobes 2002; Gulliver et al. 1995; Rohsenow et al. 1997), and the degree of nicotine dependence among alcoholic smokers is positively related to alcohol cue reactivity (Abrams and Biener 1992). In addition, a study of hazardous drinkers (i.e., those scoring 8 or above on the Alcohol Use Disorders Identification Test [Babor et al. 1992]) found that 6 hours of nicotine deprivation was associated with increased alcohol cravings during exposure to smoking cues (e.g., cigarette lighter, ashtray, pack of favorite cigarettes) as well as increased alcohol consumption during a taste test procedure (Palfai et al. 2000). Alcohol cravings also were increased during neutral cue exposure, suggesting that stopping one drug of abuse and not another may result in cross-cue reactivity that places a person in recovery at increased risk for relapse (Bobo et al. 1998; Toneatto el al. 1995).

CHALLENGES IN TREATING CO-OCCURRING SMOKING AND ALCOHOLISM Unfortunately, even with today's best interventions for tobacco cessation, smokers in alcohol treatment or recovery face particular challenges to their cessation efforts. On average, compared with smokers who do not abuse substances, alcoholic smokers are more addicted to nicotine, smoke higher nicotine cigarettes, smoke more per day, and score higher on nicotine dependence measures and on carbon monoxide assessment (Burling and Burling 2003; York and Hirsch 1995). Many smokers with alcoholism report that they use smoking to cope with their urges to use alcohol or other drugs (Rohsenow et al. 2005), so alcohol-dependent smokers may have stronger views about the benefits of continued tobacco use than do other smokers. In addition, nicotine positively influences information processing among alcoholics (i.e., nicotine use increases the speed and accuracy of information processing) (Ceballos et al. 2006), which may decease motivation to change. Thus, researchers and clinicians must take into account the characteristics of tobacco dependence in alcohol-dependent populations when determining how best to treat these patients' tobacco dependence.

SUMMARY Despite concerns to the contrary, the majority of empirical evidence indicates that smoking cessation (whether through formal treatment or self-initiated change) does not pose a risk to successful alcoholism treatment. Not only does smoking cessation not disrupt alcohol abstinence, it actually may enhance the likelihood of longer-term sobriety. Although research has yet to determine the extent to which smoking cessation is impeded by active alcohol use difficulties, the presence of these difficulties does not prohibit achievement of tobacco abstinence. Given the substantial negative health consequences of co-occurring cigarette smoking and alcoholism, smoking cessation efforts in the context of treatment for alcoholism are likely to yield important benefits to patients physically, emotionally, socially, and economically.

ACKNOWLEDGEMENTS This work was supported by the following grants: DA016138 awarded to Barbara W. Kamholz, Ph.D.; 1R01-AA013727 awarded to Domenic Ciraulo, M.D.; 2R01-AA1164201A awarded to Dena Davidson, Ph.D.; and the Veterans Administration Research Enhancement Award Program (REAP) awarded to Ronald Goldstein, M.D.

FINANCIAL DISCLOSURE The authors declare that they have no competing financial interests.

REFERENCES: Available at below source link Source link:

John (Gold)
John (Gold)

8:27 PM - Mar 26, 2007 #2

Myth: Smoking is more benign than alcoholism.
  • More people with alcoholism die from smoking-related diseases than from alcohol-related illness (Hurt et al. 1996).
  • Comorbid smoking and alcoholism result in synergistic exacerbation of health risks (Bien and Burge 1990; York and Hirsch 1995; Hinds et al. 1979).
Myth: Smokers with comorbid alcoholism have either no interest or no ability to quit smoking.
  • The majority (up to 80 percent) of individuals in addiction treatment are interested in quitting smoking (cf. Prochaska et al. 2004).
  • Inclusion of smoking cessation treatment into other addiction programs does not negatively affect rates of treatment completion or motivation for abstinence (Sharp et al. 2003; Monti et al.1995).
  • Alcoholism does not seem to impede specific attempts at quitting smoking (Hughes and Kalman 2005).
  • Alcoholism may make lifetime cigarette abstinence more challenging, but it remains possible (Martin et al. 1997; Prochaska et al. 2004).
Myth: Smoking cessation will impede successful alcohol use outcomes.
  • The majority of research indicates that smoking cessation is unlikely to compromise alcohol use outcomes (cf. Fogg and Borody 2001).
  • Participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs (Prochaska et al. 2004).
  • Data indirectly suggest that continued smoking increases the risk of alcohol relapse among alcohol-dependent smokers (Taylor et al. 2000).
Last edited by John (Gold) on 11:06 PM - Feb 16, 2009, edited 1 time in total.

John (Gold)
John (Gold)

8:33 PM - Mar 26, 2007 #3

Joel's Reinforcement Library

Can people quit smoking
and still drink alcohol?

There are different groups of people that must be taken into consideration when addressing alcohol and quitting: people who have never taken a drink in their lives, people who are truly social drinkers, drinkers who consider themselves to be social drinkers but who may in fact have a drinking problem, people who know that they are alcoholics and who have quit drinking, and people who are actively drinking alcoholics. There are different considerations involving quitting for each of these groups.

Never Drinkers

The easiest group of course is people who have never been drinkers and don't plan on ever drinking. There is nothing they need to worry about regarding alcohol consumption when quitting smoking.

Social Drinkers

Truly social drinkers can still drink alcohol without risk of smoking relapse--but being mentally prepared can be crucially important for them. They must go into ALL drinking situations reminding themselves that they are recovering nicotine addicts and that they are going to be recovering nicotine addicts for the rest of their lives.

While that may not sound great in concept--being a recovering nicotine addict--it sure beats being an actively using nicotine addict, hands down. For over time, being a recovering nicotine addict has no real signs or symptoms and no real adverse health or even social effects associated with it. Being an active user would actively be destroying tissue with every puff, depositing cancer-producing chemicals with every puff, assaulting your heart and circulatory system with every puff, costing you money with every puff, and making you reek with every puff.

It is important for these people to know that know that everything that they could do as smokers, they can also do as ex-smokers. They just have to teach themselves how. There are some things that new quitters are forced to learn early on like how to eat, sleep, use the washroom, breathe, etc. These are things that are required from day one for survival. So even though they may resist doing one of them, they can't resist for long and will thereby be forced to start to break the association to smoking early on.

Other things are sometimes put off and seen as unimportant to face early on. Tasks like doing housework, laundry, cleaning, brushing teeth, combing hair, or maybe even going to work and doing their jobs. While it is true that people won't die if they stop doing one or more of these activities for a day or two, putting off doing them too long will create a set of problems that can be quite annoying to those around them.

Besides threatening their livelihood and making them look like slobs in general, if carried on too long, it can really start to make them feel intimidated that they may never again be able to do these activities. Again, it must be repeated, everything a person did as a smoker they can also do as an ex-smoker--but they have to teach themselves how.

Now when it comes to areas of less importance like watching television, sports, playing cards, being a couch potato, and yes, even drinking with friends--things that are not necessary for survival and in fact, things that may not even be good for a person--well, the truth is people can do these things too as ex-smokers.

The same process is necessary though. They have to teach themselves how. Holding off too long can create a sense of intimidation, the feeling that they can never do the specific activity again. This simply is not the case. They will be able to get themselves back to their pre-quitting existence if they choose to.

Drinking is a special case because the association is so strong and by its very nature lowers their inhibitions. It can cause people to do some very irrational behaviors. Smoking can be one of them. Because of the drug's influence, it is best that people take it on gradually, in the beginning in a safe environment.

These people should probably limit themselves to one drink the first time out just to show themselves that they can have a drink without smoking. Also, they should do it with people who are non-smokers and who really are supportive of their quitting. This is a much safer situation in the beginning than going out with drinking buddies who smoke cigarettes and who may be a tad envious of their quitting, and who, while drinking themselves also have their inhibitions lowered. It may manifest in behaviors of encouragement of smoking at a time when the person is more vulnerable.

Soon ex-smokers will be able to face these environments too. Again it is best that they do it gradually, breaking some of the association and intimidation factors in the safer controlled environments. The fact is, though, for the rest of their lives they will need to keep their guard up, in a sense reminding themselves of their reasons for having quit and the importance to stay off smoking, every time before they go drinking. It prepares them to face the situation in a much safer state of readiness.

These people need to use timetables that they are comfortable with, but the sooner they take on activities like drinking the sooner that they will prove to themselves that life goes on without smoking.

Problem Drinkers

The next group is people who define themselves as social drinkers but who do in fact have a drinking problem. These are people who cannot drink in a controlled manner, or people whose drinking at one time has adversely affected their health or caused them any economic, professional, legal, or personal problems.

These people need to think long and hard about whether they are in fact problem drinkers or possibly dealing with alcoholism issues. If a person says that they know that their drinking will cause them to take a cigarette and relapse back to smoking, and then they take a drink and relapse, they are in effect problem drinkers for they have now put their health on the line in order to drink.

Recovering Alcoholics

A person who has acknowledged that he or she is an alcoholic and has successfully quit drinking probably has a rather thorough understanding of addiction. If he or she didn't, he or she would not be successfully off drinking but more likely rather still is an active drinker. People who are successfully recovering from alcoholism probably understand the relapse implications of just one drink, or just one sip.

All a person who has quit drinking needs to do to quit smoking is to just transfer his or her experience and knowledge with alcohol, while aiming it straight at nicotine. The same problem -- drug addiction. The same solution -- stop delivering nicotine into his or her system.

The recovering alcoholic will probably be scared about quitting, feeling that life will never be the same without smoking. " The odds are pretty good that he or she probably had those exact same fears when quitting drinking. The recovering alcoholic was right when he or she thought his or her life would be different. It in all likelihood became immeasurably better. The same will hold true with quitting smoking.

I always state it this way. Treat an addiction as an addiction and a person will learn to control it. Treat an addiction like a bad habit and the person won't have a prayer. Nicotine use is an addiction. If a recovering alcoholic takes his or her understanding of addiction and aims it at nicotine he or she will do fine.

I should point out that whenever I have a person who quits smoking after quitting another substance, he or she often has a harder time quitting than the average smoker. Smoking may have been a crutch used to help them get off of the other substance. Now, when quitting cigarettes, not only is the person trying to break free from a primary addiction, but he or she is also trying to remove the crutch that he or she feels supported recovery from the other addiction.

While it may be harder up front, people recovering from alcoholism or any other addiction can be more prepped for success than the average quitter, for once again, they understand addiction. If the quitter aims their alcohol recovery program at treating this addiction, they will do fine with nicotine dependency recovery, too.

Drinking Alcoholics

The last group is people who are actively drinking alcoholics who want to quit smoking. When it comes to nicotine addiction, the only thing these people need to do to successfully quit smoking is to stop delivering nicotine. Are there other things that some people may also have to get rid of after they quit smoking? Sure there are.

If a person were a diabetic while smoking and not watching his or her diet, he or she would likely have to get his or her sugar intake under control when quitting smoking. The fact is, though, he or she probably needed to get his or her sugar under control when he or she was still smoking. Quitting didn't change that variable. Alcohol is no different. If a person has a drinking problem before quitting, he or she will still have a drinking problem after quitting. Still, all the problem-drinker needs to do to get off nicotine is just to get off nicotine. The drinking problem still exists and still needs to be dealt with.

A person first realizing he or she has an alcoholism problem and who also wants to quit smoking either has to quit both substances at the same time or get drinking under control first. The only reason I say that some people probably need to quit drinking first is because of the limitation of how the person's alcohol treatment program will advise him or her when they find out that he or she is a recent quitter of cigarettes.

Many if not most alcohol recovery programs will inadvertently or very purposely push a new ex-smoker entering the program to smoke. Over the years I have in fact had actively drinking alcoholics in smoking clinics--people who made it abundantly clear that they knew they had drinking problems and smoking problems but wanted to treat the smoking first.

I really do try to get them into alcohol treatment concurrently but cannot force them to do it. On more than one occasion I have seen the person successfully quit smoking, stay off for months and sometime longer, and finally get into AA, only to be assigned a smoking sponsor who tells the person that he or she can't "get off smoking and drinking at once," and who actually encourages the person to smoke again.

Note the sequence here--the ex-smoker has been off of nicotine for an extended time period but the smoking sponsor says that the person can't quit both at once. It is unfortunate that most alcohol and drug treatment programs just don't recognize smoking as another drug addiction.

You will not often see an AA sponsor say that you can't give up drinking and heroin at once, so if you have been off heroin for six months and now want to quit drinking, you should probably take heroin for a while until you get alcohol out of your system.

The bottom line is that there are other things that ex-smokers may need to address but not in order to sustain their quits, but to sustain their health or control other problems. To successfully overcome smoking and arrest a dependency upon nicotine requires only that a smoker make and stick to a personal commitment to Never Take Another Puff.

© Joel Spitzer 2005

Page created October 29, 2005 and last updated by Joel Spitzer on October 29, 2005

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John (Gold)
John (Gold)

9:15 PM - Mar 26, 2007 #4

Below are selected paragraphs the following article. A link to the full text of this public domain article is at the bottom of the post.

Barriers and Solutions to Addressing Tobacco Dependence in Addiction Treatment Programs
Douglas M. Ziedonis, M.D., M.P.H.; Joseph Guydish, Ph.D., M.P.H.; Jill Williams, M.D.; Marc Steinberg, Ph.D.; and Jonathan Foulds, Ph.D.
Douglas M. Ziedonis, M.D., M.P.H., is a professor and chair, Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts.
Despite the high prevalence of tobacco use among people with substance use disorders, tobacco dependence is often overlooked in addiction treatment programs. Several studies and a meta-analytic review have concluded that patients who receive tobacco dependence treatment during addiction treatment have better overall substance abuse treatment outcomes compared with those who do not. Barriers that contribute to the lack of attention given to this important problem include staff attitudes about and use of tobacco, lack of adequate staff training to address tobacco use, unfounded fears among treatment staff and administration regarding tobacco policies, and limited tobacco dependence treatment resources. Specific clinical-, program-, and system-level changes are recommended to fully address the problem of tobacco use among alcohol and other drug abuse patients.
Tobacco dependence is one of the most common substance use disorders and a leading cause of morbidity and mortality in addiction treatment programs (American Psychiatric Association [APA] 2006; Ziedonis and Williams 2003). Not surprisingly, people who successfully maintain abstinence from alcohol and other drugs often will prematurely die from tobacco-caused diseases such as coronary artery disease, chronic obstructive pulmonary disease, lung cancer, etc. (Hurt et al. 1996). Multiple biological, psychological, and social factors account for the high co-occurrence of alcohol and tobacco dependence, including genetic evidence showing that people with genetic vulnerability to one disorder also are vulnerable to the other. The common genetic vulnerability may be located on chromosome 2 (Bierut et al. 2004; True et al. 1999; See also the article by Grucza and Bierut in this issue).
Despite the existence of effective, evidence-based nicotine dependence treatments, tobacco dependence is commonly ignored in addiction treatment programs. Why has tobacco dependence treatment not been routinely integrated into addiction treatment programs? What are the barriers? Interestingly, 100 years ago the treatment of alcohol, opiates, and cocaine problems included treating tobacco dependence (Hoffman and Slade 1993). Addiction was perceived as a unitary problem, and the use of either the primary substance or any other substance use was considered a potential trigger for the primary addiction. What led to the decision to defer to primary care for the treatment of tobacco dependence? This paper will attempt to answer these questions and to make recommendations for addressing tobacco use in addiction treatment programs.
Addiction treatment professionals eventually recognized that co-occurring mental illness and addiction needed to be addressed in the context of addiction treatment programs. Likewise, members of this field are beginning to recognize that there also is a need to integrate tobacco dependence treatment across the continuum of substance abuse treatment and prevention services. Improved health services interventions for tobacco dependence are needed at the clinical, program, and system levels (Stuyt et al. 2003). Clinical-level change requires better screening and assessment of nicotine dependence and the inclusion of tobacco dependence in the treatment plan. Staff training is necessary and an important first step to address attitudes, skills, and knowledge. Staff who traditionally treated "alcohol dependence only" have adapted their skills and knowledge to treat other co-occurring substance use disorders such as marijuana or cocaine addiction. A similar transformation could occur for co-occurring alcohol and tobacco dependence. In addition to staff training, other program-level interventions include developing models that integrate the treatment of alcohol and tobacco dependence, staff training on assessing and treating tobacco dependence, and continuous quality improvement on this topic. Broader system-level interventions include increasing collaboration between health and behavioral health providers, developing policy changes to promote addressing tobacco, and providing financial support for tobacco dependence treatment.
This article reviews commonly perceived barriers to addressing tobacco and health services interventions that can help addiction treatment programs better recognize and treat tobacco dependence.
In addition to program culture and financial barriers to treating tobacco dependence, staff attitudes, skills, and knowledge all influence the lack of attention given to tobacco in addiction treatment programs. Staff attitudes set the tone as to whether tobacco dependence will be addressed; tobacco-dependent staff often are the most resistant to change (Bobo and Davis 1993; Asher et al. 2003; Williams et al. 2005; Hurt et al. 1995). Treatment wisdom discourages major life changes during early recovery for fear of relapse, and the treatment culture has accepted that "quitting tobacco" would be a major life change-although quitting other substances simultaneously is not (Sussman 2002; Joseph et al. 2002).
Staff Attitudes and Tobacco Use
About 30 to 40 percent of addiction treatment staff in community-based programs are tobacco dependent (Bernstein and Stoduto 1999) compared with about 60 to 95 percent of patients (APA 2006; Lasser et al. 2000; Richter et al. 2004); 22 percent of the general population (Centers for Disease Control and Prevention [CDC] 2005); and 3 to 5 percent of physicians, dentists, and dental hygienists (Goldstein et al. 1998; APA 2006). Staff members who smoke most likely are not going to try to help a patient quit smoking-sometimes as a result of their own guilt and shame about their own smoking. In the authors' clinical work and role as trainers to other professionals, staff members who smoke often support smoking with their patients as their way to promote a better "therapeutic alliance." Although spending nontreatment time with patients can be positive (such as taking walks, sharing meals, etc.), engaging in addictive behaviors with a patient is inappropriate and unhelpful for recovery. Smoking with patients also normalizes tobacco addiction and even enhances its value as a therapeutic event. An early first step in program change can include policies to restrict staff smoking with patients. This policy change promotes the addiction professional's role in promoting health and recovery instead of reinforcing the use of substances to manage feelings and cope with stress.
Providing tobacco-dependent staff with the resources, support, and encouragement for their own tobacco dependence treatment is important for their health, their family's health, and the patient's health. In addition, employers have recognized the value of having nonsmoking staff. Health care costs are 40 percent higher for smokers than nonsmokers. In addition, employees who smoke spend about 18 days a year on smoking breaks, cost a company drug plan about twice as much, and are absent from work 26 percent more often than nonsmokers (Tobacco Free Oregon 2003). More employers are recognizing that tobacco use in the workforce reduces productivity and increases costs, and, as a result, some employers have changed their hiring practices and policies regarding employee smoking. More employers are helping staff who smoke to quit but also are only hiring nonsmoking staff.
Lack of Training
Staff members in addiction treatment settings often receive little or no training in treating tobacco dependence. Fortunately, addiction counselors know how to treat other addictions, and the learning curve is quick and often very rewarding when applied to tobacco. The lack of training for most staff members reflects the field's blinders to this topic-but this is changing.
Providing staff training enhances skills and knowledge-and also changes attitudes. With appropriate skills and knowledge, staff members often recognize that part of their role is to treat tobacco dependence-and that this is not just primary care's responsibility. They can better appreciate that tobacco use must be addressed because of the increased morbidity and mortality among their patients. In addition, environmental tobacco smoke (ETS) affects both smokers and nonsmokers. Children, people with existing cardiac disease, and older adults are particularly vulnerable to the health consequences of ETS. Many staff members are surprised to learn that tobacco use is the number one preventable cause of death in the United States (CDC 2001) (see Figure). More addiction treatment programs and clinicians are recognizing that addressing tobacco dependence is important for promoting wellness and recovery. All smokers should be encouraged to seek tobacco dependence treatment at some point in their recovery, and addiction treatment staff can readily learn to use the evidence-based psychosocial treatments and integrate their use with appropriate medications (including several over-the-counter options). System-level reminders to trigger staff to screen, assess, and treat tobacco dependence routinely are needed to ensure that tobacco dependence treatment skills are utilized (Ziedonis et al. 2006). Strategies for treating patients at all levels of motivation to quit are important. Effective brief interventions for addressing tobacco dependence in less motivated smokers have been evaluated (Steinberg et al. 2004) and may be useful for addressing tobacco in addiction treatment populations.

Clinical Lore Training staff members to treat tobacco dependence also helps change the treatment culture by correcting many of the misconceptions or "clinical lore" about tobacco-such as "tobacco is not a real drug," "it's too hard to address all the substances together," and "quitting tobacco will definitely worsen other substance recovery." Clearly, tobacco is both addictive and deadly-even if the serious health consequences are not immediate and do not disrupt the patient's life as dramatically as other substances with regard to legal, employment, and family problems. Patients are apt to minimize the impact of all their drug use, especially when the consequences are not immediate and visible. Staff members know how to address this type of rationalization and denial regarding other substances. For programs that continue to allow smoking at breaks, there are opportunities to observe patients' regressive behaviors during breaks-when many behaviors can shift back to a "bar scene." Staff members can effectively discuss these changes during treatment, as they may mirror prerelapse risk behaviors after discharge.

Some staff members believe that quitting tobacco would be too stressful during treatment. Of course, some patients who smoke will not object, and some patients may also believe that they do not have to stop marijuana when they quit alcohol or stop alcohol use when their primary drug is heroin. Patients may express their own concerns that the urge to smoke will be intolerable, withdrawal will be very difficult, quitting will affect their primary recovery, and they may actually need cigarettes to help them cope with stress (Asher et al. 2003). In fact, evidence suggests that the opposite can occur-that tobacco use can harm, rather than enhance, recovery from other substance use by its ability to trigger other substance use (Williams et al. 2005; APA 2006).

Another potential barrier is that some staff may believe that their patients are just not interested in quitting smoking. As a result, the staff will not discuss the issue of tobacco dependence and quitting. However, many substance abusers are interested in quitting smoking as part of recovery (Ziedonis and Williams 2003; APA 2006). Although more than half of patients who smoke believe that quitting smoking will be the hardest addiction for them to address (Kozlowski et al. 1989), there is evidence that tobacco addiction can be treated successfully in addiction treatment programs, both immediately and later in the recovery process. In a recent meta-analytic review of randomized trials of smoking cessation in substance abuse settings, Prochaska and colleagues (2004) concluded that patients engaging in tobacco dependence treatment had better overall substance abuse treatment outcomes at 6 months after treatment compared with those who did not engage in tobacco dependence treatment. The exact best timing for an individual patient is less clear (Joseph et al. 2004); however, the key is to assess and make a plan to treat tobacco dependence at some point during treatment and/or recovery.

Smoke-Free Buildings and Resistance to Smoke-Free Grounds Secondhand tobacco smoke poses a real health risk to everyone exposed to the smoke, and the issue is well addressed in the recent Surgeon General's Report on Secondhand Smoke (U.S. Department of Health and Human Services 2006). The Textbox below lists the key findings from this report. The need to provide clean indoor air has resulted in policy changes to require smoke-free buildings in many workplaces and public settings, including health care facilities. Although there was initial resistance to smoke-free buildings by some addiction treatment staff, State laws and requirements set by the Joint Commission on Accreditation of Healthcare Organizations have changed the norm to smoke-free buildings for treatment. In addition to smoke-free buildings, some inpatient workplaces (including addiction treatment programs) have taken an additional step toward addressing tobacco by implementing "smoke-free grounds." This step means that tobacco smoking is not allowed anywhere on the grounds of the addiction treatment program, rather than just being prohibited in the buildings. Having entirely tobacco-free grounds is an additional policy change that some States have now mandated for their treatment programs (see Sidebar on pp. 236-240).

Staff members who smoke often initially oppose the "smoke-free grounds" level of program change. Program leaders, administrators, or staff members also may have concerns that patients will act out, have worse withdrawal, leave against medical advice (AMA), or seek treatment at competing programs that allow smoking. Contrary to expectations, treatment programs with smoke-free grounds often report less acting out, less haggling about smoke breaks/number of cigarettes allowed, less coercion of smokers by either peers or staff, no increase in the AMA discharge rate, increased likelihood of completed treatment, and an increase in the number of patients seeking treatment (APA 2006; Williams et al. 2005; Hurt et al. 1995).

Other cultural milieu barriers are subtle. Some programs still sell cigarettes with the profits contributing to one of the few "discretionary" funds to which these programs have access. The projected loss of these funds obviously contributes to administrative resistance to this change. Some addiction treatment programs are housed within psychiatric care facilities with even less attention to tobacco use.

Limited Treatment Resources Available treatment resources-especially coverage for tobacco dependence treatment medications-often are limited for tobacco-dependent staff and patients. This is especially problematic for patients who may have limited income and are underinsured or uninsured. In the general population, psychosocial behavioral therapy alone can be as effective as medications alone in the treatment of tobacco dependence (APA 2006). However, there is a much greater likelihood of receiving only medications for tobacco dependence treatment. Integrating psychosocial tobacco dependence treatment into addictions treatment is an effective way to overcome some of the financial issues. For example, psychosocial treatment interventions in addiction treatment programs commonly address multiple drugs for any individual because other drugs (including tobacco) are triggers for the primary addiction. Integrating smoking cessation into routine addiction psychosocial treatment helps the primary addiction and does not require additional billing specific to tobacco dependence to the insurance company. As with other multiple addictions, charges for psychosocial treatment are bundled so that programs address multiple problems under the primary substance use disorder. Many inpatient programs either do not have tobacco dependence treatment medications on their pharmacy formulary or the options are very limited. Outpatient programs are more reliant on the patient's health care benefits or willingness to pay out of pocket for these medications. Although the cost of over-the-counter nicotine replacement still is less than the cost of a carton of cigarettes, most patients still perceive that this out-of-pocket cost is too high and feel entitled to benefits covering those costs-even if they are not covered.

SOLUTIONS Over the past 10 years, many addiction treatment agencies have begun to better address tobacco dependence and have benefited from program-level interventions (Stuyt et al. 2003). One organization doing these health services interventions-the University of Medicine and Dentistry of New Jersey (UMDNJ) Tobacco Dependence Program-has helped many addiction treatment programs incorporate evidence-based tobacco dependence treatment into ongoing practice. In some cases, these programs have adopted a "motivation-based treatment" model to address tobacco dependence, which does not require abstinence by the patient, but all patients who are tobacco dependent get screened, assessed, and offered some type of treatment.

Although addiction treatment programs use urine toxicology screens and breathalyzers to screen for alcohol and other drugs, most do not screen for tobacco use with a carbon monoxide (CO) meter. The CO meter is a good measure of tobacco smoking exposure and can be used as an effective tool to motivate patients to seek tobacco dependence treatment (Steinberg et al. 2004).

Education and other motivational enhancement interventions can help less motivated patients to incrementally increase their commitment to quit. For example, information about health risks, wellness interventions (stress management, nutrition, and exercise), Stage II Recovery, available medication and other treatments, local and online Nicotine Anonymous meetings, and other community treatment resources (e.g., State-supported Internet sites and telephone quit lines) can immediately help motivate some individuals. Others may save this information for a later quit attempt. More motivated patients can aim for tobacco abstinence and be effectively treated when psychosocial and medication treatments are blended into the "treatment as usual." Program-level interventions include staff training, policy changes, and, in some cases, establishing smoke-free grounds.

An initial health service research study has found that the UMDNJ program intervention can be effective in addressing tobacco dependence at the residential treatment program level, and another more rigorous health services study funded by the National Institute on Drug Abuse (NIDA) currently is underway to study this approach in the context of three community-based treatment programs within the NIDA Clinical Trial Network. The UMDNJ Tobacco Dependence Program co-leads this project and provides consultation and training to the programs. The consultation follows the steps outlined in the Textbox below.

Developing a leadership team with a game plan is a necessary first phase of the program intervention. Through that process the organization's "motivational level" for addressing tobacco can be better determined. Meaningful change requires local champions of the change process. Resources of time and money are needed. Paradigm shifts are required, and staff training is essential. Because tobacco dependence is insidious in most addiction treatment programs, the leadership team should include representatives from the whole organization (i.e., administration, staff, union, housekeeping, security, grounds, etc.). Some system changes include modifying standard intake forms to include a comprehensive tobacco dependence assessment, including tobacco on the treatment planning forms, providing patient education literature, posting pro-wellness posters and no-smoking signs, and starting local Nicotine Anonymous groups. Other changes can include developing policies specific to tobacco use, labeling smoker's charts, changing the name of "smoke breaks" to just "breaks," not allowing staff members to smoke with patients, and providing nicotine replacement therapies or other Food and Drug Administration-approved medication for smokers on the inpatient units and possibly at other levels of care.

When implementing tobacco-related policy changes, it is helpful to ensure that such changes are not solely perceived as losses (e.g., we have all just lost our right to smoke). It may be helpful to provide a pleasant alternative during the transition. Individual programs should come up with strategies that work for them. One program, for example, replaced smoke breaks with "popcorn breaks," with the agency providing free popcorn.

Tobacco-dependent patients should have the resources available (including trained staff) to help them quit, and patients and staff members who do not smoke should not be exposed to the toxins of ETS. There are clear barriers to addressing tobacco use and dependence, but there also are effective ways to address these barriers and promote the integration of evidence-based tobacco dependence treatment into addiction treatment programs.

The addiction treatment community as a whole now has an opportunity to denormalize tobacco use for the field by tailoring traditional tobacco control strategies to the unique issues of the addiction treatment and recovery community. Denormalization of tobacco use includes making smoking behavior not the norm and providing education about the health risks of tobacco products and the activities of the tobacco industry (e.g., Truth Campaign [Thrasher et al 2004]).

Although tobacco control strategies have effectively denormalized tobacco use in the general population (Hammond et al. 2006), these strategies have not targeted people with substance use disorders. Tobacco control efforts within the addiction treatment and recovery community could help the field to recognize and manage tobacco dependence as any other substance use disorder. Denormalization strategies in this setting would include assessing and treating tobacco dependence in treatment programs, maintaining smoke-free buildings and grounds, eliminating the sale and advertisement of tobacco products, improving understanding of the impact of smoking in the home on the children of people in recovery, and perhaps revealing how the tobacco industry may target people with other addictions (many of their ads link alcohol and tobacco). Targeted mass media campaigns have been effective in reducing tobacco use in the general population, and opportunities exist to develop a media campaign for the addiction treatment and recovery community. The leaders of Alcoholics Anonymous, Bill W. and Dr. Bob, were both smokers and died of tobacco-caused diseases before the health consequences and addictive nature of tobacco use were fully recognized. Undoing the "normalization of tobacco" that has occurred within the addiction treatment and 12-Step community for the last generation will need input from everyone involved in the treatment, prevention, and recovery community.

CONCLUSION Tobacco dependence is one of the most common addictions among people with alcohol and other drug addictions-and a leading cause of morbidity and mortality in addiction treatment programs. Now is the time for addiction treatment programs to better address tobacco dependence at the clinical, program, and system levels. Many programs have been successful at doing so. Then there are real and perceived barriers to address, but as with recovery from any substance, the first step is to acknowledge the need for change. There are then many successful ways to begin and support that change.

Link to full text:

John (Gold)
John (Gold)

9:37 PM - Mar 26, 2007 #5

The full-text of the above article encourages training on nicotine dependency recovery and recommends sending staff members to a host of facilitator / counselor certification programs referenced in the article. I submit that when it comes to nicotine dependency recovery that it is very possible that the most extensive and effective facilitator learning and education environment is right here at Freedom.
A wonderful starting point for any addiction counselor finding their way to this thread is a complete cover-to-cover read of "Never Take Another Puff," Joel Spitzer's free 148 page PDF book. It is loaded with amazing insights, almost all of which will dove-tail nicely into any existing alcohol treatment program.
So long as there is never any charge or cost to those receiving it, and it is not used for financial gain, the book may be freely printed and shared. Explore the following link. There, in addition to being able to download a PDF version of Never Take Another Puff, you'll find an online HTML copy of the book, and a growing collection of video counseling lessons, and Joel's guide to navigating recovery.
Last edited by John (Gold) on 11:08 PM - Feb 16, 2009, edited 1 time in total.


11:01 PM - Mar 26, 2007 #6

Video that also discusses these issues:
People in recovery from other addictions Dial up
Date added

JoeJFree Gold
JoeJFree Gold

5:57 AM - Nov 03, 2008 #7

Welcome, you are in good company. Freedom is a choice. Dependency leaves us with only two alternatives - All or none. One = All. None = Freedom.
Choose control, choose none, live free.

Joined: 7:22 PM - Nov 11, 2008

1:49 PM - May 16, 2012 #8

Characteristics of Alcoholic Smokers, Nonsmokers, and Former Smokers: Personality, Negative Affect, Alcohol Involvement, and Treatment Participation.Journal:  Nicotine & Tobacco Research 2012 May 9. [Epub ahead of print]

Authors:  Walitzer KS, Dearing RL.


INTRODUCTION:  Previous research has indicated that smoking behavior in the general population is linked to personality traits such as behavioral undercontrol and negative emotionality, but it is unknown whether these traits pertain to alcoholic smokers. Further, prior research has not established whether alcoholic smokers differ from their nonsmoking counterparts in terms of alcohol involvement severity and treatment participation. Exploration of these associations is important, given the high prevalence of cigarette smoking among alcoholics.

METHODS: Treatment-seeking alcoholics were categorized into daily cigarette smokers (n = 76), nonsmokers (n = 34), and former smokers (n = 33). These groups were compared on personality traits, negative affect, alcohol involvement, and alcohol outpatient treatment participation.

RESULTS: All three groups scored similarly on a variety of personality traits (e.g., extraversion and neuroticism), and on most aspects of negative affect, with the exception of anxiety (smokers scored higher than nonsmokers and former smokers). In terms of alcohol involvement, alcoholic smokers reported greater negative drinking consequences and alcohol physical dependence relative to former smokers, even considering that alcoholic smokers had relatively more abstinent days. Finally, alcoholic smokers attended considerably fewer alcohol outpatient treatment sessions relative to both nonsmokers and former smokers.

CONCLUSIONS:  Common risk factors for both alcoholism and smoking behavior, such as personality traits and negative affect, may obscure personality differences between smokers and nonsmokers in an alcohol treatment sample. Furthermore, findings suggest that current nicotine use among alcoholics is associated with greater anxiety and severity of alcoholism than among their former-smoking counterparts.

PMID: 22573729 [PubMed - as supplied by publisher]
PubMed Link: