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

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

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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. The average weight gain is only 2–3 kg over a five-year period, compared with those who smoke. Some quitters gain considerably more weight; however, one in five lose weight or stay the same.

The withdrawal symptoms will be Withdrawal symptoms can usually be controlled with optimal use of stop-smoking medications and unbearable. behaviour change strategies.

be managed with similar behavioural and interviewing, lifestyle changes, and stress levels are common in this population pharmacological treatments as others management. and stress management techniques who smoke, but may require more It is important to explore the substance should be discussed in all cases. Regular intensive and longer care.3,4 Management user’s beliefs about smoking. Identifying exercise and a healthier diet may also is based on the five As framework their misperceptions and providing help.4 Encourage the patient to avoid outlined in The Royal Australian College corrective information can often trigger boredom by developing new interests and of General Practitioners’ (RACGP's) an attempt to quit smoking (Table 1). It is keeping busy. Supporting smoking cessation: A guide for especially important to discuss the greater Advise reduced contact with peers health professionals (Table 2).22 health risks of smoking, compared with who also use drugs and alcohol as this It is important to identify and treat other drug use, and explain that quitting will lessen the risk of relapse to smoking mental illness when it co-exists with a multiple drugs simultaneously is generally and other drug use. It can be motivating dependence on alcohol and other drugs more effective than sequential treatment. to discuss alternative uses for the money as this can improve smoking and drug Smoking behaviour needs to be saved by quitting smoking as many people treatment outcomes.3,4 Explaining to considered in the broader context who use alcohol and other drugs struggle patients that smoking cessation improves of the patient’s lifestyle. High-stress financially. For those who are not currently mental health and cognitive function, and enhances recovery from alcohol and 22 other drugs, can help to motivate quit Table 2. The five As of smoking cessation for substance users attempts. Smoking cessation can also Ask Regularly ask all patients if they smoke and record the information in the lead to increased blood levels of some medical record. psychotropic drugs, particularly clozapine Advise Advise all patients who smoke to quit in a clear, personalised way such as ‘The and olanzapine, and dose adjustments best thing you can do for your children and your health is to stop smoking’. may be required soon after quitting.22 Assess Assess interest in quitting, level of nicotine dependence, psychiatric comorbidities and other drug use. Counselling Assist Provide personalised information. People who are dependent on alcohol Identify smoking triggers and discuss coping skills. and other drugs and smoke generally Address barriers to quitting such as effect of quitting on other drug use. need more comprehensive and longer Make environmental and lifestyle changes. behavioural counselling than others Recommend medication. 3,4 who smoke. Many of the strategies Advise ‘not even a single puff’. for alcohol and drug treatment are also Set a quit date. used for smoking cessation, such as Arrange Follow-up visits increase long-term abstinence. providing information, identifying triggers, Patients who use substances are less likely to attend. avoiding high-risk situations, motivational

ready to quit, consider motivational adherence and no sustained cessation medication for an extended course of six interviewing and address anticipated benefit.28 months. He will also use nicotine mouth barriers to quitting (Table 1). Where GPs Alternative treatments need to spray for quick relief of breakthrough are unable to provide counselling, patients be considered in this more resistant cigarette cravings. can be referred to: population. Electronic cigarettes may James agrees to try to cut down on • Quitline (137 848) have a role and are commonly used by his alcohol consumption to two drinks • an accredited tobacco treatment those who use illicit drugs in Australia.8 A per day on five days per week. He also specialist (www.aascp.org.au) recent review concluded that electronic agrees that if he cannot achieve this and • a psychologist, with a GP Mental Health cigarettes can help those who smoke to maintain it within six months, he will aim Care Plan where appropriate. quit and reduce cigarette consumption. for abstinence. The review also concluded that electronic Pharmacotherapy cigarettes were 95% less harmful than Conclusion The same medications for smoking smoking tobacco.29 However, there is still Users of alcohol and other drugs are cessation are used in people who use some controversy about their use, and at high risk of harm from smoking, yet alcohol and other drugs as those who long-term efficacy and safety data are not their use of tobacco is often neglected. smoke. First-line agents are nicotine yet available. Wherever possible, GPs should integrate replacement therapy (NRT), varenicline smoking cessation treatment into the and bupropion. Optimal therapy and longer Case – Alcohol dependence routine care of patients who are dependent than standard treatment courses are James, 42 years of age, is a storeman on alcohol and other drugs and also smoke. recommended; however, the additional with an alcohol problem. He is divorced Many of these patients are willing and medication costs can be a barrier in this and has been drinking heavily for the able to quit smoking, but may need more population.3,4 past 10 years. His alcohol consumption intensive and longer treatment. Perceived Given the higher levels of nicotine has increased to a bottle of whisky each barriers to quitting are common and should dependence, larger than average doses of evening to relax and ‘numb the pain’ be addressed. Concurrent treatment NRT may be required to relieve cravings since his marriage broke down six months of smoking and other substances is and withdrawal symptoms. Combination ago. James chain-smokes when drinking recommended in most cases and does not NRT (nicotine patch plus a quick acting and smokes up to 30 cigarettes per day. increase relapse to alcohol or other drugs. preparation such as the mouth spray He says cigarettes are like a friend and Authors or lozenge) is more effective than the provide companionship when he is alone. 23 Colin P Mendelsohn MBBS (Hons), Tobacco patch alone and will usually be required. James has chronic depression, but has not Treatment Specialist, The Sydney Clinic, Bronte, NSW. Varenicline is the most effective single been taking his medication for some time. [email protected] agent for smoking cessation, although You discuss the strong association Alex Wodak AM, FRACP, FAChAM, MBBS, Emeritus Consultant, Alcohol and Drug Service, St Vincent’s there is sparse evidence for its use in between alcohol and smoking, and how Hospital, Darlinghurst, NSW 24 smokers with illicit drug problems. The each drug triggers urges for the other. He Competing interests: Dr Mendelsohn has received combination of varenicline and nicotine is more likely to achieve and maintain payments from Pfizer Australia, GlaxoSmithKline Australia and Johnson and Johnson Pacific for patch may be more effective than long-term sobriety if he quits smoking. teaching, consulting and conference expenses. 25 varenicline alone. Although smoking seems to relax him, Provenance and peer review: Not commissioned, In smokers with alcohol dependence, it actually increases stress levels and externally peer reviewed. combination NRT has been shown to depresses his mood overall. You discuss References be more effective than a single nicotine strategies to reduce stress, such as taking 1. Hurt RD, Offord KP, Croghan IT, et al. Mortality product.26 There is also a growing evidence the dog for a walk and deep-breathing following inpatient addictions treatment. 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