Treating Smokers With Current or Past Alcohol Dependence

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Treating Smokers With Current or Past Alcohol Dependence

ABSTRACT: About 80% of alcoholics currently smoke and many appear nicotine dependent. Conversely, 15% of smokers have a current and 40% have a past alcohol problem. Most smokers with present or past alcohol problems are interested in treatment for smoking. Whether such smokers should try to stop smoking during, soon after or long after stopping alcohol is unclear. Smoking cessation rarely induces a relapse back to alcohol use. Whether smokers with a history of alcoholism need more intensive or different treatment is unclear. Preliminary data suggest such smokers are more nicotine dependent and are especially benefitted by nicotine replacement.

Extensive reviews of the association of smoking and alcoholism are available.( 1-4) The present article will focus on the treatment of smoking cessation in the context of past or present alcoholism.

Most alcoholics are smokers. When alcoholics in treatment are compared to the general population, the prevalence of heavy smoking is 72% vs 9%, of light smoking is 11% vs 21%, of ex-smoking is 17% vs 28% and of never smoking is 8% vs 42%.( 5) Thus, not only are alcoholics more likely to currently smoke, but they are also much more likely to be heavy smokers and are much less likely to have never smoked or to have stopped smoking. A similar pattern of findings occurs with cocaine( 6) and opioid( 7) abusers and with adolescent alcohol/drug abusers.( 8)

Conversely, many smokers are active alcoholics.( 9) In two surveys, 14 to 15% of smokers had current alcoholism, and 35-45% had a lifetime history of alcoholism.( 9, 10) In one of these surveys, the probability of alcoholism increased from never to ex- to light to heavy smokers( 9) Furthermore, because alcoholic smokers are not stopping smoking at nearly the rate of smokers in the general population, then future populations of smokers will have more and more alcoholics, and the association of smoking and alcoholism will become even stronger over time.( 11)

Treating Smoking in the Context of Alcoholism

There has been a growing interest in treating smoking among alcoholics due to several events: (a) the JCAHO mandate that alcohol treatment centers be smoke-free, (b) the recent consensus that smoking is a form of drug dependence,( 12) (c) the development of effective behavioral and pharmacological therapies for smoking,( 13) (d) the interest of many alcoholics in recovery in smoking cessation therapy,( 14) and (e) the experiences of chemical dependency counselors seeing those successfully treated for alcoholism die of smoking-induced disorders soon after recovery.

Three major obstacles to implementing treatments for smoking in alcoholics have been (a) the concern that smoking cessation can threaten sobriety, (b) the different clinical and research traditions of the treatment of alcohol and nicotine dependence (i.e., most existing treatments for alcoholism are based on clinical experiences( 15) whereas most treatments for smoking are based on experimental studies( 13)), and (c) lack of knowledge about treating nicotine dependence among chemical dependency personnel. Of these three, the first is perhaps the one of most concern, in part, due to conflicting evidence. One prospective clinical study reported that among smokers who had a past but not present history of alcoholism and who stopped smoking, 18% either relapsed to alcohol use or had to return to smoking to avert such a relapse.( 16) One retrospective study found that 13% of alcoholic smokers who first quit drinking and later quit smoking reported increased craving for alcohol when they stopped smoking.( 17) Another prospective study found a nonsignificantly greater relapse to illicit drugs among inpatient substance abusers treated for smoking cessation.( 18)

On the other hand, three other prospective studies( 19-21) and one retrospective study( 17) found none of the smokers who were former alcoholics returned to drinking after stopping smoking.( 17) Another prospective descriptive study found that alcoholics who later quit smoking were less, not more, likely to return to alcohol use.( 22)

In summary, it appears that most recovering alcoholics can stop smoking without any threat to their sobriety, but there may be a small minority of such smokers who need to be followed closely to prevent relapse to alcohol use.

Whether smokers with a past history of alcoholism need more or different therapy for smoking cessation is debatable. Three prospective clinical trials have reported that on a given attempt to stop smoking, smokers with such a past history were 30-65% less likely to stop smoking than were smokers without this history.( 19, 20, 23) Another prospective( 20) and a retrospective( 24) trial did not find this. In addition, retrospective trials reported that 44-63% of alcoholics in recovery went on to eventually stop smoking, a rate that is comparable to that found in the general population, that is, 45% of ever-smokers eventually stop smoking.( 5, 25) Thus, whether recovering alcoholics smokers are less likely to stop smoking (and therefore need more intensive therapy) is unclear.

In terms of content of the treatment, there are only a few controlled studies of treating smoking in the context of alcohol or drug abuse (Table 1). Two studies examined treatment for smoking while alcoholics were hospitalized for treatment of their alcoholism.( 26, 27) One study examined homeless veterans who were alcoholics and in residential treatment for alcoholism?( 28) Another study used a contingency management program to help cocaine and opioid addicts stop smoking.( 29) A final study examined whether increased doses of methadone would help opioid addicts stop smoking.( 7) All five of these studies reported low rates of cessation (0-15%). One other study reported that a combination of cognitive behavior therapy, 12-step-based therapy, and nicotine gum produced 32-38% quit rates at early follow-up (3 month) compared to 17% in the control group.( 30)

Whether alcoholic smokers are more nicotine dependent than smokers without alcoholism and therefore especially need nicotine replacement has only begun to be tested. Two studies reported moderate correlations between scores on the Alcohol Dependence Scale and time to the first cigarette (a marker for nicotine dependence) or Fagerstrom score for severity of nicotine dependence (r = .19-.32).( 31, 32) One retrospective study reported that smokers with a history of alcoholism were more likely to be diagnosed as moderately-to-severely nicotine dependent and reported more severe withdrawal than did smokers without this history.( 33)

A fourth study reported no difference in overall Fagerstrom score and no difference in withdrawal symptoms between smokers with and without a history of alcohol problems during a prospective clinical trial; however, several of the individual items of the Fagerstrom, including the time to first cigarette, indicated smokers with the history were more nicotine dependent.( 19) This latter study also reported a post hoc finding that smokers with a past history of alcohol problems were especially benefitted by nicotine replacement therapy; that is, after 1 month, 45% of such smokers who received nicotine gum were abstinent compared to 23% of those who received placebo gum. In summary, no trial has reported inducing significant long-term smoking cessation in recovering alcoholics.

Although the epidemiological data cited at the beginning of this article suggest smoking cessation rarely occurs prior to resolution of alcohol problems, another survey reported many less-severe alcoholics had stopped smoking prior to stopping drinking.( 21) Several arguments can be made for stopping smoking while stopping alcohol; for example, the absence of smoking cues could decrease urge to use alcohol.( 34) Arguments can also be made for stopping smoking after stopping alcohol; for instance, stopping two dependencies at once is too difficult.( 34)

There are several possible treatments for smoking in alcoholics that have not been tested. For those trying to stop both alcohol and smoking at the same time, clonidine and naltrexone might be helpful. Clonidine abates alcohol withdrawal symptoms( 35) and it increases rates of smoking cessation by a factor of 1.5 to 2.0.( 36) Naltrexone decreases relapse back to alcohol use in alcoholics( 37, 38) and may be helpful in smoking cessation.( 36) In terms of psychosocial therapies, a 12-step therapy for smoking cessation might be more beneficial than a traditional behavior therapy for those who underwent 12-step therapy for their alcohol problems.( 39) Finally, motivational enhancement therapy appears to help motivate alcoholics to stop drinking.( 40) Perhaps this intervention could be expanded by evaluating and intervening on both smoking and drinking together.

Clinical Implications

The major implications of the above information appear to be as follows:

Current and future treatment interventions for smoking will need to screen for and treat alcoholism because many smokers have current alcohol problems.
Current and future treatments for alcoholism will need to provide smoking cessation therapies to satisfy client interest and because smoking cessation can allow recovering alcoholics to enjoy their recovery longer.
Smoking cessation does not threaten the sobriety of most alcoholics but close monitoring is necessary to prevent relapse to alcoholism in the small proportion for whom this may be a problem.
Treatment of alcoholism should either come first or be at the same time as treatment for smoking because few smokers can stop smoking unless their alcoholism is treated.
Because there is no good data on the subject, recovering alcoholic smokers interested in stopping smoking should decide whether it is best to do so at the same time, soon after or long after treatment for alcoholism.
Because there is limited and contradictory information on whether recovering alcoholics need more or different treatment for smoking, the standard treatments given for smoking should be used in this population.
As evident in the above summary, there are many unanswered questions about treating smoking in the context of alcoholism. Given the large interest in the area, there is a pressing need for empirical studies.

ACKNOWLEDGEMENT

Preparation of this article was funded, in part, by grant AA-09480 from the National Institute of Alcohol and Alcohol Abuse and Research Scientist Development Award DA-00109 from the National Institute on Drug Abuse.

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Article copyright PNG Publications.

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By John R. Hughes

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