Smoking Cessation During Substance Abuse Treatment

Cigarette smoking is pervasive among persons who are being treated for substance use disorders. The prevalence is 3- to 4-fold higher than in the general population. Whereas approximately 20% of adults in the United States currently smoke, between 75% and 95% of persons in treatment programs for addictions are cigarette smokers.^1-3 The consequences of dual addictions to cigarettes and other substances of abuse are dire. In a frequently cited study conducted over a decade ago, approximately 50% of patients who were followed after inpatient substance abuse treatment died of tobacco-related causes—a rate that exceeded deaths from alcohol(Drug information on alcohol)-related causes (34%).³ These high tobacco-related mortality rates reflect not only the greater prevalence of smoking in this population but also the tendency for persons with substance abuse disorders to start smoking at a younger age, to be more dependent on nicotine(Drug information on nicotine), and to be particularly susceptible to certain types of cancer secondary to combined use of tobacco and alcohol (eg, cancers of the head and neck).^4-6

Smoking cessation interventions are critical for improving the health and quality of life for persons in treatment for or in recovery from alcohol and other substance use disorders. Unfortunately, such interventions have been underutilized because of a number of individual, organizational, and cultural barriers. There has been much progress over the past several decades in recognizing the importance of treating tobacco addiction in persons with other substance use disorders, yet many of the historical barriers remain entrenched in the attitudes of individuals and in organizational culture.

In this article, we provide an overview of the critical issues involved in overcoming personal and organizational barriers to help substance abusers quit smoking. To highlight both the opportunities and the challenges of this work, we include illustrative statements from patients who decided to tackle both addictions at once as part of the Clean Break smoking cessation group at the Cincinnati VA Medical Center. This group is made up of veterans in the residential substance dependence treatment program who receive combined behavioral and pharmacological treatment. (See Heffner JL et al,⁷ for a more detailed description of the program and its short-term outcomes.)

The effect of smoking cessation on sobriety

“I heard at AA that you shouldn’t quit everything at the same time. It’s too much of a shock to the system and might make you want to go back to drinking. Also, I really wanted to do some cocaine when I was out on my weekend pass so I thought it was better to do the less dangerous drug. It was either cocaine or smoke.”

Unfortunately, it is not uncommon to hear individuals in substance abuse treatment programs express the belief that smoking cessation would be harmful to sobriety, or conversely, that cigarette smoking facilitates sobriety by reducing urges to use other substances. Although it is tempting to characterize such statements as individual rationalizations to smoke, these attitudes are frequently espoused by treatment providers, mutual support group (eg, Alcoholics Anonymous or Narcotics Anonymous) sponsors, and family members. However, there is little evidence to suggest that smoking cessation has a negative impact on treatment for or recovery from substance use disorders. In fact, an overwhelming majority of studies suggest that smoking cessation interventions either have a positive effect on sobriety or are unrelated to abstinence from alcohol and illicit drugs.^8-10 One well-designed study did detect worse 30-day and 6-month drinking outcomes for individuals who received a smoking cessation intervention during residential substance abuse treatment (ie, concurrent treatment) than for those who received the intervention 6 months later (ie, delayed treatment).¹¹ Nevertheless, the differences in alcohol outcomes observed for delayed treatment compared with concurrent treatment were not consistently significant on all measures of alcohol consumption at all follow-up points.¹¹

In working with patients to address the belief that smoking cessation increases the risk of alcohol and drug relapse, we have found that sharing anecdotal evidence rather than citing research findings tends to be a more powerful motivator to reexamine such beliefs. Thus, learning more about the experiences of fellow smokers in treatment or recovery who have successfully quit smoking can be very helpful.