“Clearly there exist many barriers to simultaneous treatment of tobacco dependence and other substance use disorders,” the investigators observe. “However, most alcoholics in treatment are concerned about their smoking and the preponderance of evidence indicates that trying to quit during substance use disorder treatment does not interfere with sobriety and, in fact, appears to be associated with better alcohol and other drug use outcomes.”
Kalman and colleagues are among a growing number of clinicians and researchers calling for the recognition of (and interventions for) tobacco dependence as a common comorbidity with other substance use and psychiatric disorders. Brian Hitsman, PhD, Northwestern University, Chicago, and colleagues published their review of evidence-based interventions for tobacco dependence in persons with mental health or addictive disorders a few months earlier, finding several psychological and pharmacological interventions supported by clinical data.2 They indicate that interventions to stop smoking should be offered along with treatments for psychiatric and substance use disorders to not only mitigate the health issues of tobacco but to improve mental health treatment outcomes.
“Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal,” Hitsman and colleagues propose, “extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in mental health and addictive disorder treatment settings and in the community.”
Kalman and colleagues point out that while the overall rate of smoking in the United States has declined, the rates in both treatment-seeking and community-dwelling alcoholics have remained significantly elevated—estimated by some to be as high as 80% in clinical populations. They relate evidence that the adverse health effects of chronic alcohol and tobacco use are synergistic: the level of risk is multiplied for conditions that are associated with both, including cancers of the upper respiratory and digestive tracts.
An NIMH report3 published in December 2008, “Tobacco Use and Cessation in Psychiatric Disorders,” for which Hitsman was a coauthor, documented an exceptionally high rate of smoking among psychiatric patients. The report considers possible biological, psychological, and social factors for this, including the lack of smoking cessation treatments available in mental health settings. The NIMH report notes that “self-medication” and “individual rights” have historically been concerns used to rationalize continued tobacco use in mental health treatment programs. The report rejects these as reasons for not offering effective treatment to psychiatric patients who have tobacco dependence and criticizes the extent to which tobacco use may have been accepted to “self-medicate.”
“Although research has shown that tobacco use can reduce or ameliorate certain psychiatric symptoms,” the NIMH report indicates, “overreliance on the self-medication hypothesis to explain the high rates of tobacco use in psychiatric populations may result in inadequate attention to other potential explanations for this addictive behavior among those with mental disorders.”
