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Smoking Cessation in People with Alcohol and Other Drug Problems

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Smoking Cessation in People with Alcohol and Other Drug Problems CLINICAL Smoking cessation in people with alcohol and other drug problems Colin P Mendelsohn, Alex Wodak AM Background eople who are dependent on alcohol Prevalence and other drugs have very high In 2007, 73% of people in Australia with People who consume alcohol and other P smoking rates and are far more drug-use disorders and 61% of those with drugs are at particularly high risk of likely to die from a smoking-related illness alcohol dependence smoked, compared harm from smoking, yet tobacco use is than from their primary drug problem.1,2 with 22% of the population overall.7 commonly neglected in this patient group. Smoking cessation in this at-risk group The smoking rate in people who are dependent on alcohol and other drugs Objectives is often rated as a lower priority and frequently delayed or ignored.3–5 has remained high in recent decades, The objectives of this article are to People with risky use of alcohol and while declining appreciably in the general 8 increase awareness of the high risk of other drugs frequently present with a community. tobacco-related harm in people who crisis that is usually given precedence Several explanations have been consume alcohol and other drugs, identify over smoking. In addition, there are proposed for this high-sustained smoking 9,10 the barriers to quitting and provide many misconceptions about smoking rate. There is a shared genetic practical guidelines to assist quitting. cessation in this population that predisposition to nicotine and other undermine intervention. For example, drugs of dependence. Nicotine and other Discussion addictive drugs trigger the release of health professionals often think that dopamine in the reward pathway, which People who are dependent on alcohol people who are dependent on alcohol creates pleasure, and co-administration and other drugs are far more likely and other drugs are unmotivated or has an additive effect that enhances to die from a smoking-related illness unable to quit smoking.5 In addition, enjoyment. Mental health conditions are than from their other drugs. Most are many people with alcohol and other drug motivated to quit smoking; however, common in people who are dependent problems incorrectly believe that quitting their quit rates are lower than in the on alcohol and other drugs who may use will undermine their recovery from other general population. Substance users who nicotine to relieve psychiatric symptoms.9 drugs or that smoking relieves stress.6 also smoke can usually be treated with Smoking is also a gateway to illicit drugs11 This article examines why general similar behavioural and pharmacological and is part of the drug-taking culture. treatments as others who smoke, but practitioners (GPs) should prioritise generally require more intensive and smoking cessation in substance users Health impact longer treatment. Quitting smoking at who also smoke. It also explores the Many people who are dependent on the same time as undergoing other drug relationship between smoking and other alcohol and other drugs, as well as health treatment does not undermine drug drugs, particularly alcohol, cannabis, professionals, underestimate the relative treatment outcomes and may improve opioids and stimulants (Box 1), and the health risk of smoking, compared with them. Smoking cessation should be disproportionate adverse health effects other drug use.12 Substance users are at integrated into the routine care of from smoking in people who consume particularly high risk of harm because of patients who consume alcohol and alcohol and other drugs. Common barriers high smoking rates, heavier smoking and other drugs. to intervention are described, along with earlier initiation.3 There is also a synergistic practical strategies for helping patients interaction between smoking and alcohol, who are dependent on alcohol and other which amplifies some health risks (eg drugs to quit smoking. head and neck cancers).13 © The Royal Australian College of General Practitioners 2016 REPRINTED FROM AFP VOL.45, NO.8, AUGUST 2016 569 CLINICAL SMOKING CESSATION Box 1. Smoking and specific drugs be undermined by misguided concerns. Common fears are that quitting smoking Alcohol10,20 will jeopardise recovery from other drugs • Nicotine and alcohol each enhance the enjoyment of the other through their common action in the reward pathway, where both trigger the release of dopamine. or that it will remove a coping tool for 6 • Drinking alcohol increases the urge to smoke, partly due to the disinhibiting effects of alcohol managing withdrawal from other drugs and conditioned association of the two behaviours. (Table 1). • Smoking increases the urge to drink and is a risk factor for relapse to alcohol after alcohol Although people who consume alcohol treatment. and other drugs smoke more heavily and • Smoking counters the sedative and cognitive effects of alcohol and reduces the severity of are more nicotine dependent than others alcohol withdrawal. who smoke, some do quit smoking.3 • Long-term quit rates are low, especially in heavy drinkers. However, quit rates are lower than in the Opiates3,17 general population and relapse is more • Users of opiates and opioid agonists (eg methadone, buprenorphine) have the highest smoking common.3,15 The lowest long-term quit rates (>85% smoke). rates are in opiate and cocaine users.3,16,17 • Methadone may increase the reinforcing effects of cigarettes. People who use methadone smoke more heavily in the four hours after each dose. Smoking cessation • Nicotine attenuates some side-effects of methadone such as sedation and reduced attention. improves substance use • Opiate users have high levels of psychiatric comorbidity and stress, and may use smoking as an anxiolytic or antidepressant. outcomes • Most opiate users are interested in quitting smoking but long-term quit rates are very low. Despite misperceptions to the contrary, quitting smoking improves long-term Cannabis30 abstinence from alcohol and illicit drugs. • About 50% of adults with cannabis-use disorders are currently smoking tobacco. For example, one study found that alcohol • Two out of three users combine cannabis with tobacco (‘mulling’), which can lead to nicotine dependence and cigarette smoking. and drug users who quit smoking in the • Quitting both together is recommended as continuing to use cannabis can make quitting first year after treatment were two to tobacco harder. three times more likely to be abstinent • Cannabis and tobacco have similar withdrawal syndromes and the combined symptoms may from these drugs nine years later than be more severe. those who continued to smoke.18 • Behavioural strategies used for tobacco can also help reduce or stop cannabis. Most of the evidence supports Stimulants (eg cocaine, meth/amphetamine)31,32 concurrent treatment for tobacco and other • More than 80% of people who use stimulants smoke tobacco. drugs. A meta-analysis of 19 randomised • Cocaine administration increases cigarette smoking and nicotine use increases the severity of controlled trials found that patients who cocaine use. were treated simultaneously for smoking • Nicotine withdrawal (quitting smoking) is associated with reduced cravings for stimulants. and other drug problems were 25% more • A recent study has found that quitting smoking during stimulant treatment improved smoking likely to achieve long-term abstinence from abstinence and did not undermine stimulant outcomes. alcohol and other drugs than those who did not receive a smoking intervention.19 Smoking can trigger relapse to alcohol or Many patients with alcohol and other believe that smoking helps them to cope other drugs.20 Similarly, relapse to smoking drug problems overcome their primary with stress, the opposite is true. Smoking is more likely when drug use is continued. addiction, then die from a tobacco-related actually increases stress levels overall Furthermore, if smoking cessation is illness.3 One study found that 51% of and people who smoke report reduced delayed, many patients will not return for patients who were followed for 10 years anxiety, improved mood and quality of life follow-up, resulting in missed opportunities after inpatient alcohol and drug treatment after quitting.14 to provide treatment.21 died of tobacco-related causes.1 In another study of people dependent on Motivation and quit rates Management heroin, the mortality rate of those who Contrary to popular belief, substance Users of alcohol and other drugs should smoked was four times that of those who users who smoke are as motivated to be routinely asked about their smoking did not smoke at 24-year follow-up.2 quit smoking as those who smoke in the status and offered help to quit. Similarly, People with alcohol or other drug general population.3,5,15 Most have tried patients who smoke should be asked problems have high rates of mental to quit repeatedly and many have made about alcohol and other drugs. People illness and often smoke to relax or reduce a serious attempt to quit in the previous who are dependent on alcohol and other stress. Although many people who smoke year.3 However, motivation to quit can drugs and who also smoke can generally 570 REPRINTED FROM AFP VOL.45, NO.8, AUGUST 2016 © The Royal Australian College of General Practitioners 2016 SMOKING CESSATION CLINICAL Table 1. Common smoking myths and responses6 Myth6 Response Smoking is a lower priority than other drugs. Those who are alcohol or drug dependent and smoke are far more likely to die prematurely from a smoking-related disease than from their primary drug problem. Smoking relieves stress. Smoking actually increases stress levels overall.14 Much of the apparent calming effect of smoking is due to the relief of nicotine withdrawal. Quitting smoking will undermine recovery Quitting smoking generally improves drug or alcohol treatment outcomes.19 from other drugs. It is best to stop one drug at a time. Concurrent treatment of nicotine and other drugs is preferred wherever possible and increases success rates overall.19 Quitting causes massive weight gain.
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