The bad news

• Smoking is the most common form of drug addiction and contributes directly or indirectly to 25 percent of all deaths in this country.
• Many people in recovery from other addictions die because of smoking.
• Nicotine kills more people each year than all other drugs combined.
• Relapse rates for smoking are frequently worse than for alcohol and other drugs and addictive behaviors.
• Smokers who are active in other addictions and compulsive behaviors may have a lower success rate in smoking cessation or be more likely to relapse.

This points to the importance of a comprehensive treatment approach for long-term recovery.

Nicotine addiction’s relationship with other addictions and compulsive behaviors and the power that smoking has to moderate strong feelings and depression are explored in the self-help book, Recovery from Smoking, Quitting with the 12-Step Process. This book is useful with clients in private practice and is used as the basis for the Caron Foundation’s inpatient nicotine addiction program, which was recently evaluated for effectiveness over a five-year period. Results confirm the importance of addressing strong affect, depression, other addictions and compulsive behaviors, when treating the smoker.

Addiction-interaction disorder

How does nicotine interact with other addictions? Using Patrick J. Carnes’ model of “addiction-interaction disorder,” it appears that the interaction of nicotine with alcohol, caffeine, food and sex addiction reinforce or counteract each other through withdrawal mediation, alternating addiction cycles, ritualizing, lowering inhibitions and affecting a variety of addictive patterns. Nicotine has the power to numb and mediate strong feelings and affect symptoms of depression. These interactions have implications for the successful treatment of nicotine addiction.

Rituals

Powerful reinforcing connections are created when smoking is paired with other drugs and addictive behaviors. In addiction-interaction disorder, one addictive behavior serves as a catalyst to create a ritual pattern to engage in another. A two-pack-a-day smoker feeds the addiction 40 times a day, taking 140,000 drug “hits” a year. These nicotine hits are often in combination with other addictive substances, such as caffeine, alcohol and other drugs. The nicotine fix comes fast, too. The effect of a drug that is smoked is much faster than the effect of intravenous administration, explaining an additional reason for the power of this addiction. It takes 10 seconds for 25 percent of the nicotine in each drag to reach the brain. This is powerful reinforcement for the trance-inducing rituals associated with smoking.

These puffs may help the smoker dissociate and lower inhibitions for acting out with other addictions including, but not limited to, codependency, chemical addictions, compulsive gambling, workaholism, sex and romance addiction, rageaholism, and religious addiction.

Clinical judgment indicates that when smoking rituals are used with other chemicals or addictive behaviors, and addiction interactions are not recognized, abstaining from one addictive substance alone cannot be expected to lead to long-term abstinence.

One client said that he never thought about smoking cigarettes unless he was smoking marijuana. He said that while he was getting high with friends, he could smoke up to a pack of cigarettes in a single evening. He couldn’t imagine smoking cigarettes without getting high, and he couldn’t recall a time when he used marijuana without also smoking cigarettes.

Nicotine’s moderation of strong affect

I used nicotine in a precise way to control my feelings... Any intensity of feeling that I experienced was a cue to smoke a cigarette.”

— Recovery From Smoking: Quitting with the 12-Step Process

When smokers are active in nicotine addiction, the 140,000 drug hits per year, combined with changing the style of puffing to pep up or calm down, consistently numb and alter the level of the effect to match the momentary drug load.

Nicotine suppresses feelings. During withdrawal and early recovery, feelings often emerge with frightening intensity that can lead to relapse. Exercises canhelp nicotine addicts increase their affect tolerance. It is important to work with clients to help them manage strong feelings. In the follow-up research conducted at the Caron Foundation, strong feelings proved to be the greatest difficulty and primary triggers for relapse. Nicotine and alcohol Approximately 80 percent of alcoholics and drug addicts are also nicotine addicts. Many smokers who are recovering alcoholics and drug addicts worry that if they stop smoking they will relapse with alcohol and drugs. This seldom happens. In fact, 80 – 85 percent of the recovering alcoholics in recent research reported no relapses or increased cravings for alcohol when they stopped smoking. Stopping smoking may actually help recovering alcoholics and drug addicts not relapse with alcohol and drugs. This may further indicate that the addiction-interaction disorder involving nicotine and alcohol needs to be treated as an entity, not as separate substance addictions.

Nicotine addiction may mask other addictions, such as alcoholism. Approximately 15 – 20 percent of heavy smokers have current alcohol problems. In the chronically relapsing smoker, nicotine is starting to be viewed as a probable marker for undiagnosed alcoholism. Unless these smokers stop drinking, it is unlikely they will be successful in smoking cessation. Abstinent smokers who continue to drink alcohol are more likely to return to smoking. It is common for recovering nicotine addicts to report that they smoked more when drinking alcohol and believe that nicotine helped keep them more awake and more alert. Is it possible that when nicotine and alcohol are used simultaneously, the sedative effect of alcohol may be counteracted by the stimulant effect of nicotine or the stimulation produced by increased acetylcholine during the rapid puffing of nicotine? It appears that the combination of nicotine and alcohol produces a powerful reinforcing effect, probably through the mechanisms of addiction-interaction disorder. What is the neurochemistry of this interaction disorder? The research questions and ideas are fascinating. Nicotine and caffeine Recognizing the interaction of nicotine and caffeine addictions is essential to smoking cessation success. Nearly 86 percent of smokers report drinking coffee, a major source of caffeine. Smoking increases the metabolism of caffeine. When people stop smoking and don’t change their caffeine intake, the caffeine levels in the blood increase by 50–60 percent. So newly recovering nicotine addicts suffer increased anxiety and restlessness due to the effect of caffeine intoxication. One female client who had recently stopped smoking on her own without reducing her 10-cup-per-day coffee habit illustrates an example of this. She relapsed with nicotine attributing her intense anxiety to nicotine withdrawal. It was most likely caffeine intoxication that she was experiencing. Clearly, it’s easy to attribute this overdose of caffeine to nicotine withdrawal. If this form of addiction interaction is not addressed, the smoker is likely to relapse with smoking, believing that only nicotine can relieve the distress while not recognizing this powerful interaction has occurred. When people stop smoking, research shows that they actually decrease their anxiety. It is important not to let the addiction interaction between nicotine and caffeine take away this wonderful benefit of smoking cessation. Nicotine and food “This was a big one for me — my fear of getting fat ran a close second to my fear of losing control in withdrawal.... I often thought about cigarettes and craved sweets.... Instead of eating candy and drinking milk shakes like my craving directed, I drank orange juice and ate fruit. When I drank orange juice, the craving for sweets passed... Decreasing my sugar intake helped reduce my cravings, both for food and cigarettes.” Recovery from smoking Smokers in early recovery complain of food cravings that lead to addictive eating and weight gain. Instead of craving a cigarette after eating, the smoker in early recovery craves sweets or simply continues eating compulsively. Nicotine affects insulin production and it takes about three months for insulin to stabilize. Alternating one addiction with another is characteristic of addiction interaction disorder. This is a common pattern with nicotine and food. Active smokers may begin cessation and substitute food for cigarettes. Abstinent smokers may cycle back to nicotine to avoid further weight gain. Both addictions numb feelings and promote uninhibited behavior. Instead of alternating addictions, nicotine and food addiction may occur at the same time. Compulsive restriction of food intake may interact with nicotine to produce a simultaneous increase in both addictive behaviors. Also, nicotine can be used to numb shame associated with addictive binges and is effective in lowering inhibitions for binge eating.

Follow-up research at the Caron Foundation showed that 87 percent of the smokers gained weight after stopping smoking. Women were twice as likely as men to gain weight This finding is consistent with patients in private practice and indicates the necessity of acknowledging this interactive process and treating both smoking and food addiction in recovery.

Nicotine and sex addiction

Many smokers crave a cigarette after sex. While the mechanisms of interaction between sex and nicotine are unclear, the explanation for this craving may go beyond the reduction of nicotine withdrawal symptoms or the need to distance from intimacy.

Clients describe the ritual of rapid cigarette puffing and compulsive masturbation. This is an example of pairing and interaction of ritualized addictive behaviors. Nicotine is effective in numbing strong feelings of shame and despair associated with addiction. Also, smoking is an effective way to tune out, increase obsessive thinking and lower inhibitions for addictive acting out. These clinical impressions are leading to the development of research questions in this interesting area.

Some sex addicts who are nicotine addicted report obsessing on pornography that involves smoking. In fact, there are support groups for those who have fused smoking and sex. People who engage in cruising, in many cases, seek out situations in which people smoke because it is erotic for them. For example, one client reported spending many hours circling middle schools looking for young adolescent girls smoking, and smoking while watching them. While the mechanisms have not yet been researched, it is clearly a problem of addiction interaction.

Nicotine and depression

Research has shown a significant relationship between depression and addictions. Confirming this, 50 percent of the patients in the Caron Foundation study reported having received treatment for depression and 59 percent of the patients have taken medication for anxiety or depression. While 90 percent of the abstinent women said their depression worsened after abstinence, only 10 percent of the abstinent men said they became more depressed. This gender difference is also consistent with other current research findings.

Nearly 30–40 percent of smokers have a history of depression. Private practitioners have reported this for years. When clients are depressed, they experience withdrawals that are more difficult and they are likely to relapse. It is important to evaluate and treat depression before smoking cessation begins and continue to monitor and treat depression during early nicotine abstinence to decrease the probability of relapse of both smoking and depression symptoms. (It is interesting to note that recent research indicates an antidepressant called bupropion has shown effectiveness in reducing nicotine cravings.)

In the Practice Guideline for the Treatment of Patients With Nicotine Dependence, The American Medical Association lists psychotropic medications that interact with nicotine to make them stronger or weaker. It is recommended, therefore, that clients consult with their physicians to monitor and advise if they need to increase or decrease their medication as they work on nicotine abstinence. Nicotine’s interaction with psychotropic drugs is important to consider for successful recovery.

The neurochemical mechanisms underlying depression’s interaction with nicotine and other addictions are open to speculation. Current research with dopamine and other neurotransmitters holds promise and may revolutionize the entire area of addiction, providing support for the Carnes’ model of addiction- interaction disorder.

Treatment

Physical, emotional and spiritual self-care and 12-step support are essential for addiction treatment. It is becoming increasingly recognized that multiple addictions can reinforce, support or counteract each other. If their interactions are not identified and incorporated in treatment planning, relapse may be inevitable.

Elizabeth H. Hoffman is a recovering nicotine addict and clinical psychologist. Christopher D. Hoffman, also a recovering nicotine addict, is a licensed clinical social worker. They both provide therapy, staff training and consultation in areas of psychological interest and addictions, including nicotine addiction. Their book, Recovery From Smoking, Quitting With The 12-Step Process has been updated and revised, Hazelden, 1998. They may be reached at Hoffman Psychological Associates, 3029 N. Front Street, Harrisburg, PA 17110-1222, 717-232-6011.