The negative health effects of tobacco use are well known. It’s no secret that alcoholics and drug addicts are heavy tobacco users, but many addiction treatment programs and professionals remain reluctant to tackle nicotine addiction head-on. While recent research suggests positive benefits from simultaneous treatment of nicotine and alcohol/other drug addiction, many in the addiction treatment field have yet to fundamentally change the way they do business when it comes to nicotine-addicted patients. This article presents the basic facts about tobacco use and nicotine addiction, and discusses the barriers and advantages of providing nicotine dependence treatment in a primary alcohol and drug addiction treatment setting.

The addiction
Nicotine, one of the most powerful addictive substances, acts on the same pleasure centers of the brain as other drugs such as heroin and cocaine. The behavioral and pharmacokinetic properties that define nicotine addiction are similar to those that define addiction to other substances (NIDA, 2001).

A cigarette delivers nicotine to the brain quickly with every puff, and with 0.5 to 2 milligrams per cigarette, a person smoking one pack of cigarettes each day gets 200 “hits” of nicotine per day. The smoker learns to regulate his or her mood state by timing the delivery of nicotine to either increase attention or reduce anxiety. Tolerance to nicotine quickly develops as smokers begin to smoke more, not just to achieve the desired effects, but also to avoid the undesirable effects of withdrawal, which occur within a few hours of the last cigarette. During this time the smoker experiences craving, irritability, cognitive and attention deficits, appetite arousal, and sleep disturbances. Most smokers rapidly progress to regular use and eventual dependence on cigarettes.

The health consequences
Tobacco-related disease remains the leading preventable cause of death in the United States, claiming 430,000 lives annually. This compares with 14,000 drug-induced deaths and 81,000 deaths related to alcohol (U.S. Centers for Disease Control, 2002).

There is no safe, recommended level of tobacco smoking. Scientists have identified more than 40 chemicals in tobacco smoke that cause cancer in humans and animals. Smoking cigarettes can cause cancer of the lung, larynx, esophagus, mouth, and bladder in addition to chronic lung disease, coronary heart disease, and stroke. Smoking also contributes to cancer of the
pancreas, cervix, and kidney. Smokeless tobacco and cigars increase the risk of oral cancer, and cancer of the lung, larynx, and esophagus. Smoking accounts for one-third of all cancers, and about 90 percent of all lung cancer cases. The overall death rates from cancer are twice as high among smokers than nonsmokers (U.S. Centers for Disease Control, 1988).
Smokers also compromise the health of those around them. Involuntary exposure to environmental tobacco smoke, known as second hand smoke (SHS), increases the risk of cancer and heart disease, and exacerbates other respiratory conditions like asthma. The Environmental Protection Agency estimates that exposure to SHS causes 3,000 nonsmoking Americans to die of lung cancer annually. Nonsmokers who are married to heavy smokers have a 2 - 3 times greater risk of developing lung cancer, compared with those married to nonsmokers (U.S. Centers for Disease Control, 1994). Children of smokers are more prone to colds, bronchitis, pneumonia, ear infections, reduced lung function, and allergies than children raised in smoke-free living environments (NIDA, 2001). Smoking during pregnancy results in lower birth weight babies and increases the risk of spontaneous abortions in the first trimester.

Who uses tobacco?
An estimated 66.5 million Americans over the age of 12 currently use tobacco products; 56.3 million use cigarettes (SAMHSA, 2002). Almost two-thirds of cigarette users smoke every day. Cigarette users represented 24.9 percent of the total population according to the 2001 National Household Survey on Drug Abuse, down slightly from 25.8 percent in 1999.
Because most people who smoke cigarettes started smoking as adolescents, smoking is known now as a “pediatric disease,” a phrase popularized by David Kessler, former Commissioner of the U.S. Food and Drug Administration. While more than 13 million youths between the ages of 12 and 17 currently smoke cigarettes, the number of new initiates into tobacco use declined from 2 million in 1999 to 1.6 million in 2000, continuing a trend that began in 1996 (SAMHSA, Volume II, 2002).
People who smoke cigarettes are much more likely to use alcohol and other drugs than people who do not. Among current smokers (any use in the past month), 14 percent also used illicit drugs, compared with 3.3 percent of nonsmokers. Binge alcohol use is reported by 40.2 percent of smokers, compared with 18.2 percent of nonsmokers, and 14 percent of smokers report heavy alcohol use, compared with 3 percent of nonsmokers (SAMHSA, 2002).

Cigarettes are typically the first substance used in a progression that can eventually include the abuse of (or dependence upon) alcohol, marijuana, and other illicit drugs. It’s not that smoking necessarily causes one to use other substances, but the association between tobacco use and the use of other mood-altering substances is strong and irrefutable. For many alcoholics and addicts, nicotine is the first drug they use and the last one they quit.

The nature of this association between nicotine and alcohol/other drug use, still not fully understood, is an area of continuing research. However, there does appear to be a dose-response relationship between drinking and smoking, whereby heavy drinkers tend to also be heavy smokers. There are also marked situational linkages wherein both drugs are typically used together in the same situations (Shiffman & Balabanis, 1995). The implication of this association for prevention is that delaying the onset of nicotine use may help reduce the likelihood of other drug-using behaviors as well. For this reason, drug and alcohol abuse prevention programs that target youth are well advised to also address tobacco products.

Smoking among alcoholics and addicts
The end result of this association between nicotine and alcohol/other drug use is the high rate of nicotine dependence among those who are drug addicted and alcoholic. Among alcohol and drug dependent patient populations, the rate of smoking ranges from 71 to 97 percent (Battjes, 1988).

The smoke-filled rooms that characterize many Alcoholics Anonymous (AA) meetings also attest to the heightened prevalence of tobacco use among recovering alcoholics. Indeed, Bill W., founder of AA, died from emphysema after a lifetime of tobacco smoking, and he was not alone. In fact, more alcoholics die from tobacco-related disease than alcohol-related disease. The pioneering research study that explored this phenomenon followed up 845 patients admitted to an inpatient addiction treatment program from 1972 through 1983 (Hurt, 1996). Of the 222 subjects who subsequently died, more died of tobacco-related disease (50.9 percent) than from alcohol-related disease (34.1 percent).

“First things first” in treatment
“We’re just here to treat your addiction to drugs and alcohol. Don’t try to quit smoking now, too. First things first.” How many times have you, as an addiction treatment professional, heard this? How many times might you have been the one saying it?

Until recently, many chemical dependency practitioners went by the “conventional wisdom” of the day when it came to addressing nicotine addiction in a primary treatment setting: that quitting smoking at the same time a person was quitting other drugs and alcohol was simply asking too much. It was too tall an order. Not only that, it might endanger the hope of achieving sobriety. Some counselors and programs even adhered to the now unsubstantiated belief that quitting smoking would actually trigger a relapse to alcohol or other drugs.

Nicotine, the drug that was granted preferred political and regulatory status for a large part of modern American history, was also granted special status within addiction treatment programs. Patients in drug and alcohol addiction treatment programs were typically advised to postpone quitting their “minor” addiction to nicotine until their primary addiction to drugs and alcohol was under control, and they had maintained sobriety for a period of time. Addiction treatment programs and professionals, for the most part, completely avoided addressing their patients’ coexisting addiction to nicotine — but times have changed. We know more now than ever before about the addictive properties of nicotine. We know about the tobacco industry’s decade-long, deliberate attempts to keep secret the evidence regarding the harmfulness of tobacco. Conventional wisdom has given way to truth and science. Accordingly, it’s time for addiction treatment professionals to keep up with changing times and use their skills and expertise to facilitate recovery from addiction to alcohol, to other drugs, and to nicotine.

What does the research say?

Numerous scientific research studies have examined smoking cessation and its effect on recovery from drug and alcohol addiction, a few of which are briefly summarized below.

One research study compared abstinence rates (12-month post-treatment) for smokers versus nonsmokers and found
significantly better recovery rates for non-tobacco vs. tobacco users (Stuyt, 1997). Another study of over 900 inpatients at an alcohol and drug addiction treatment program, found that simultaneous treatment for nicotine addiction produced a temporary reduction in smoking and increased motivation to quit smoking (Joseph et al., 1990).

Still another recent, long-term research study found that continued smoking among recovering alcoholics actually increased the likelihood of relapse (Sobell & Sobell, 1996). Another study of 1,200 randomly selected health maintenance organization enrollees found that smokers who were also active alcoholics were 60 percent less likely to quit smoking than smokers with no history of alcoholism, and that recovering alcoholics were as likely to quit as smokers with no history of alcoholism (Breslau et al., 1996).

These studies and others clearly suggest that smoking cessation does not threaten sobriety or recovery from other addictions — quite the contrary — it may enhance it. Additional research will further our understanding of the interrelationships between nicotine and addiction to other substances and the implications for the treatment of both (Monti et al., 1995).

Barriers to addressing nicotine dependence in a primary treatment setting
Most people in treatment for drug and alcohol addiction are nicotine-addicted smokers. Yet at least initially, quitting smoking is the last thing on their minds. They want to quit alcohol or other drugs, NOT nicotine. In addition, they may view smoking as their single, untouchable addiction — the one mood-managing drug they can always have at their disposal. These fundamental expectations, beliefs, and circumstances represent major barriers in terms of patient motivation to quit smoking while also quitting alcohol and drugs.

While there is no easy, sure-fire method for addressing these barriers, communicating relevant information can be helpful. Patients may be more inclined to consider quitting smoking if they are educated on the harms of smoking, the health benefits of quitting, and the recent research on the connection between smoking and alcohol/other drug addiction. Knowing that quitting smoking could enhance their long-term abstinence from both nicotine and alcohol/other drugs might make patients more willing to at least consider it. And in the course of treatment, as patients learn more about the disease of addiction, the addictive nature of their nicotine use may become more apparent and subsequently influence their willingness to quit.

The barriers are equally formidable for program administrators and counselors. At the programmatic level, administrators are justifiably concerned about any type of expanded service without the corresponding, guaranteed reimbursement streams. Yet more and more insurers are covering nicotine cessation services beyond simply nicotine replacement therapies and Zyban®. And if the bottom line is the primary issue, what better way to generate continued business than with improved outcomes?
Counselors who smoke may feel personally conflicted about helping patients quit when they continue to do it themselves. Torn about not practicing what they preach, it may be easier for them — both personally and professionally — to avoid the smoking issue entirely. Others may claim they are “not trained” in nicotine addiction, or insist that it’s simply “not their job.”

Advantages of addressing nicotine addiction in a primary treatment setting
The advantages to addressing nicotine addiction in a primary treatment setting are clear. Simultaneous treatment of both addictions may reduce the risk of relapse. Treating one addiction (to alcohol or drugs) may actually enhance the success in treating the other (nicotine addiction) and vice versa. In addition, achieving and maintaining abstinence from alcohol and other drugs requires the same set of skills as abstinence from tobacco (i.e., recognizing powerlessness and lack of control, asking for help, learning to deal with cravings, learning to identify triggers, developing other coping mechanisms, and using a support system).

The support patients receive while in primary treatment for alcohol and other drugs is a powerful therapeutic tool that can also be used to help a person recover from nicotine addiction. Few environments offer more support and understanding of addiction, withdrawal, craving, and relapse prevention. Indeed, what environment could be more supportive of addressing addiction than a primary addiction treatment program?

As those who are addicted to other drugs, nicotine addicts live a life centered around acquiring and using nicotine. They protect their supply, savor each smoking moment, and become preoccupied with the next opportunity to use. If their supply runs out, they will beg, borrow or steal the next cigarette and are not above digging out and lighting up the longest, previously smoked butt from an ashtray.

Recovery from addiction, whether an addiction to nicotine or to other drugs, involves acceptance of the loss of control, accepting personal responsibility for changing the behavior, and developing a personal recovery program. Most nicotine addicts want to quit smoking, but as with addiction to other substances, they need help.
A growing number of addiction treatment programs integrates nicotine cessation into their existing programming. How? Tobacco-using patients can be required to attend a nicotine orientation group in which treatment staff present the health and other consequences of smoking, and emphasize that nicotine addiction is a “real” addiction, not just something for patients to deal with later, after they have been sober a while.

Treatment staff also debunk myths about the “best time” to quit smoking, with the latest research findings about how concurrent tobacco cessation can actually help one’s chances of long-term sobriety and freedom from cigarettes. Many patients will have preconceived notions, based on previous treatment episodes or conversations with fellow AA members, that treatment is not the “right time” to quit smoking. These need to be tackled head-on and require re-education.
For patients who seize the opportunity to quit, the counselor then develops an individualized nicotine treatment plan, which includes a designated quit date, more aptly called a “recovery date.” Before the “recovery date,” patients are encouraged to tell their fellow patients about their plans to quit, write a list of reasons to quit, and prominently display it on their mirrors. On “recovery day” patients have the last cigarette, get rid of all cigarettes and paraphernalia, and find something to do with their hands and mouth, such as chewing a toothpick or straw. Patients are encouraged to avoid smoking areas at all costs, exercise, compile a list of when they have the “urge” to smoke, talk to peers, and ask for help.

Counselors already possess the skills and abilities to help people address addiction. With counselor involvement, patients deliberately examine their nicotine addictions in the same manner that they examine their addictions to other substances. The denial system used over the years to support their continued use of tobacco is the first to be addressed. Counselors help patients examine the power of the addictive substance, the powerlessness of the individual to control the effects of the substance, and how this affects time management, relationships, and health. They can also help the patient investigate the family members who have suffered from the negative effects of tobacco use, including those who died from tobacco-related diseases. The counselor can introduce the possibility, for example, that “Aunt Faye’s heart attack” or “Uncle Jack’s stroke” was related to their years of tobacco use.

Journaling and various written exercises, such as a good-bye letter to tobacco, or an essay on how tobacco rules one’s life, can also be useful. Counselors can help reframe reactions to everyday stimuli that “trigger” tobacco use. Role-playing can help establish new, alternative ways of responding to old situations, such as, “Yes Mom, I do mind if you smoke in my house.”

Equally significant is a supportive, smoke-free treatment environment. Patient smoking should be limited to designated outdoor areas. Long gone are the days of chain-smoking treatment groups. Many AA and NA groups now promote themselves as nonsmoking groups. There are also nicotine recovery self-help groups.

Residential nicotine dependence treatment programs
Only a handful of residential programs that focus exclusively on nicotine addiction exist, including a seven-day program offered by the Hazelden Foundation; an eight-day program from the Mayo Clinic’s Nicotine Dependence Center in Rochester, Minnesota; and the Nicotine Addiction Program at St. Helena’s Hospital in Deer Park, California, to name a few.
The residential aspect enhances the likelihood of success, as shown in a recent study of patients treated at the Nicotine Dependence Center of the Mayo Clinic. Of the patients treated in its residential program, 45 percent were smoke-free at one year post-treatment, compared with only 23 percent of outpatients (Hays et al., 2001). “The most important factor that accounts for the more favorable outcomes for the residential group was the intensity of the inpatient intervention,” says Richard D. Hurt, MD, head of the center.

The supervisor of nicotine services at Hazelden, Barry McMillen, emphasizes that total abstinence from nicotine is the goal of their program. “If a person walks in using the patch or other nicotine replacement therapy, we honor that choice. But we don’t provide such treatment ourselves. Our thinking is that we have seven days to get you off nicotine and to develop strategies to remain tobacco-free for the rest of your life. If you use nicotine replacement, then you’re going to walk out of here still addicted to nicotine.” As for outcomes, 39 percent of its alumni remain continuously smoke-free after one year.
Times have changed regarding nicotine addiction and its treatment. More effective treatments for nicotine addiction are available now than ever before. Who better to facilitate the process than addiction specialists — trained professionals who understand the dynamics of addiction and realize that smoking is more than a “nasty habit?” Where better to facilitate the process than at addiction treatment programs, where addiction is already the focus of the intensive therapeutic intervention?
The benefits of dual recovery are clear. It’s time for the entire field to catch up with the science by offering services that help patients recover from nicotine dependence as well as dependence on alcohol and other drugs.

Carol L. Falkowski, director of research communications at the Hazelden Foundation, has monitored drug abuse trends for nearly 20 years through participation in an ongoing, drug abuse surveillance network of NIDA. She is president of the Minnesota Smokefree Coalition, and has provided consultation to the FDA, the National Institute of Justice, and the American Bar Association. She is the author of the book Dangerous Drugs: An Easy-to-Use Reference for Parents and Professionals.

References
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Breslau, N., Peterson, E., Schultz, L., Andreski, P., & Chilcoat, H. (1996). “Are smokers with alcohol disorders less likely to quit?” American Journal of Public Health 86 (7), 985-990.
Hays J.T., Wolter T.D., Eberman K.M., Croghan I.T., Offord K.P., & Hurt R.D. (2001). Residential (inpatient) treatment compared with outpatient treatment for nicotine dependence. Mayo Clinic Proc 76,173-181.
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This article is published in Counselor,The Magazine for Addiction Professionals, August 2003, v.4, n.4, pp. 12-17.

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