Smoking Cessation and Alcohol Abstinence: What Do the Data Tell Us?

Suzy Bird Gulliver, Ph.D.; Barbara W. Kamholz, Ph.D.; and Amy W. Helstrom, Ph.D.

Cigarette smoking and nicotine dependence commonly co-occur with alcohol dependence. However, treatment for tobacco dependence is not routinely included in alcohol treatment programs, largely because of concerns that addressing both addictions concurrently would be too difficult for patients and would adversely affect recovery from alcoholism. To the contrary, research shows that smoking cessation does not disrupt alcohol abstinence and may actually enhance the likelihood of longer-term sobriety. Smokers in alcohol treatment or recovery face particular challenges regarding smoking cessation. Researchers and clinicians should take these circumstances into account when determining how best to treat these patients’ tobacco dependence. KEY WORDS: Alcohol and tobacco; alcohol, tobacco, and other drug (ATOD) use, abuse, and dependence; alcohol and other drug (AOD) craving; AOD use pattern; AOD abstinence; alcohol and tobacco; alcohol abuse; alcoholism; smoking; cigarette smoking; nicotine; treatment program; co-treatment; treatment outcome; AOD abstinence; cue reactivity; alcohol and other drug use disorders (AODD) relapse

igarette smoking and alcohol ment for alcohol dependence has been Myth: Smoking is more benign than dependence co-occur at high avoided largely out of concern that alcoholism. The short-term effects of Crates. Research indicates that concurrently addressing both addic- alcoholism may appear more dangerous approximately 80 percent of people tions (or restricting smoking during with alcoholism smoke cigarettes and treatment for alcoholism) poses too that most of these smokers are nicotine great a difficulty for the patient and SUZY BIRD GULLIVER, PH.D., is out- dependent (Hughes 1996). Conversely, would adversely affect recovery from patient mental health site director at the smokers are at two to three times alcoholism. Such concerns are apparent VA Boston Healthcare System, Brockton greater risk for alcohol dependence both in the United States and around Campus, Brockton, Massachusetts, and than nonsmokers (Breslau 1995). the world (e.g., Walsh et al. 2005; associate professor in the Departments of Zullino et al. 2003). Myths surround- Psychiatry and Psychology at Boston ing concurrent treatment for smoking University, Boston, Massachusetts. Smoking Cessation and and alcoholism also include the ideas Treatment for Alcoholism that smoking is a benign problem rela- BARBARA W. K AMHOLZ, PH.D., is co tive to alcoholism, that patients with director, VA Boston Healthcare System Despite the fact that 60 to 75 percent comorbid alcoholism have either no Mood Disorders Clinic, Jamaica Plain, of patients in alcoholism treatment are interest or no ability to quit smoking, Massachusetts, and assistant professor of tobacco dependent and about 40 to 50 and that patients will relapse to alcohol Psychiatry and Psychology at Boston Uni percent are heavy smokers (Hughes if they quit smoking. This article versity, Boston, Massachusetts. 1995), treatment for tobacco depen- summarizes the scientific findings dence is not routinely included in that address these issues and provides AMY W. H ELSTROM, PH.D., is a clinical alcohol treatment programs. Smoking evidence-based responses to common psychologist at the VA Boston Healthcare cessation treatment (as well as bans concerns about smoking cessation dur- System and Research Associate at Boston on smoking) during the course of treating alcoholism treatment. University, Boston, Massachusetts.

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than those of cigarette smoking. into inpatient addiction treatment cen alcohol use difficulties are able to quit However, mortality statistics suggest that ters has not substantially reduced long- smoking. Though early research has more people with alcoholism die from term treatment completion (e.g., a suggested that quitting smoking would smoking-related diseases than from alco minimal drop from 75 to 70 percent at be more difficult for these patients (e.g., hol-related diseases (Hurt et al. 1996). In one site) (Sharp et al. 2003). In addition, Hughes 1996), the answer is now less addition, the greater prevalence of smok Monti and colleagues (1995) found clear. The only two studies evaluating ing in alcohol-dependent versus other that smoking rates actually decrease and this issue separate from other substances populations exacerbates health risks the motivation to quit smoking increases of abuse and co-occurring psychiatric (Bien and Burge 1990; York and Hirsch following successful alcohol treatment. disorders yielded mixed findings and 1995). Researchers have demonstrated Evidence suggests that a history of did not include more severe alcohol- synergistic carcinogenic effects for dual alcohol use difficulties may not impede dependent individuals (cf. Hughes and substance dependence. For example, the a specific smoking cessation attempt, Kalman 2005). However, studies based relative risk of laryngeal cancer has been though it does seem to reduce the likeli on smokers in substance abuse treat estimated at 2.1 in heavy smokers, 2.2 in hood of quitting smoking during one’s ment, and those in early recovery, sug heavy drinkers, and 8.1 in people who lifetime (Hughes and Kalman 2005). gest that cigarette abstinence is possible, are both heavy drinkers and heavy smok Research has yet to determine the though challenging (Martin et al. 1997; ers (Hinds et al. 1979). extent to which smokers with current Prochaska et al. 2004).

Myth: Smokers with comorbid alco holism have either no interest or no ability to quit smoking. It is interesting Myths and Data Related to Smoking Cessation to note that although addiction treatment programs routinely address multiple and Alcohol Abstinence substances of addiction (e.g., alcohol, marijuana, heroin, cocaine), tobacco is Myth: Smoking is more benign than alcoholism. frequently the sole excluded substance. • More people with alcoholism die from smoking-related diseases The scientific literature also frequently than from alcohol-related illness (Hurt et al. 1996). describes treatment of multiple nonto • Comorbid smoking and alcoholism result in synergistic exacerbation of bacco substances simultaneously, mak health risks (Bien and Burge 1990; York and Hirsch 1995; Hinds ing it difficult to evaluate the impact of et al. 1979). smoking cessation on alcoholism treat ment per se (cf. Prochaska et al. 2004). Still, evidence contradicts the notion Myth: Smokers with comorbid alcoholism have either that smokers with comorbid alcoholism no interest or no ability to quit smoking. are not interested in quitting smoking • The majority (up to 80 percent) of individuals in addiction treatment and that addictions need to be treated are interested in quitting smoking (cf. Prochaska et al. 2004). one at a time (e.g., Kalman 1998). • Inclusion of smoking cessation treatment into other addiction pro Up to 80 percent of people in addiction grams does not negatively affect rates of treatment completion or treatment are interested in quitting motivation for abstinence (Sharp et al. 2003; Monti et al.1995). smoking (cf. Prochaska et al. 2004). • Alcoholism does not seem to impede specific attempts at quitting Consistent with this, Flach and Diener smoking (Hughes and Kalman 2005). (2004) found that among dual users, approximately 75 percent wanted to quit • Alcoholism may make lifetime cigarette abstinence more challenging, both smoking and alcohol use (though but it remains possible (Martin et al. 1997; Prochaska et al. 2004). the desire to quit alcohol use was rated as higher). Furthermore, many people Myth: Smoking cessation will impede successful alcohol use outcomes. entering treatment for alcoholism are willing to quit smoking (e.g., Saxon et al. • The majority of research indicates that smoking cessation is unlikely 1997). In fact, one study found that 75 to compromise alcohol use outcomes (cf. Fogg and Borody 2001). percent of substance-dependent inpa • Participation in smoking cessation efforts while engaged in other tients accepted concurrent tobacco treat substance abuse treatment has been associated with a 25 percent ment (Seidner et al. 1996). greater likelihood of long-term abstinence from alcohol and other Inclusion of smoking as a target for drugs (Prochaska et al. 2004). intervention does not appear to reduce • Data indirectly suggest that continued smoking increases the risk of patients’ commitment to broader addic alcohol relapse among alcohol-dependent smokers (Taylor et al. 2000). tion treatment. For example, incorpo rating smoking cessation treatment

Vol. 29, No. 3, 2006 209 Myth: Smoking cessation will impede clinical contact time, reduced exposure alcoholism may interact to increase successful alcohol use outcomes. Perhaps to substance use cues, relapse prevention drinking risk. For example, alcohol most important is the concern among and/or coping skills practice, increased cues, such as the sight or smell of an treatment providers (and patients) that mastery or self-efficacy, and broader alcoholic beverage, can increase smok patients must choose between abstinence healthy lifestyle choices (Prochaska et ing urges among smokers with alcohol from cigarettes and abstinence from al. 2004). Self-initiated efforts to reduce use disorders (e.g., Cooney et al. 2003; alcohol. In contrast to this concern, smoking also may reflect increased patient Drobes 2002; Gulliver et al. 1995; research suggests that treating tobacco motivation or lower levels of nicotine Rohsenow et al. 1997), and the degree dependence within broader addiction dependence (Karam-Hage et al. 2005). of nicotine dependence among alco programs does not adversely influence Alcohol-dependent patients who holic smokers is positively related to recovery from alcoholism (or illicit sub quit smoking while in recovery from alcohol cue reactivity (Abrams and stances). Although not universal (e.g., alcohol problems also do so without Biener 1992). In addition, a study of Joseph et al. 2004), the majority of negative consequences to their alcohol hazardous drinkers (i.e., those scoring 8 findings indicate that smoking cessation or drug abstinence (Bien and Burge or above on the Alcohol Use Disorders efforts and smoking abstinence are 1990; Bobo 1989; Hurt et al. 1993; Identification Test [Babor et al. 1992]) unlikely to negatively influence alcohol Irving et al. 1994; Joseph et al. 2003; found that 6 hours of nicotine depri use outcomes (cf. Fogg and Borody Sobell et al. 1990; Sullivan and Covey vation was associated with increased 2001). In a recent meta-analysis, 2002). Data suggest that among alcohol- alcohol cravings during exposure to Prochaska and colleagues (2004) evalu dependent smokers in early recovery, smoking cues (e.g., cigarette lighter, ated the outcomes of smoking cessation nicotine deprivation is not associated ashtray, pack of favorite cigarettes) as interventions in 19 randomized con with an increased urge to drink. In well as increased alcohol consumption trolled trials with people in addiction addition, among people with signifi during a taste test procedure (Palfai et treatment or recovery. At the end of cant alcohol abstinence, evidence sug al. 2000). Alcohol cravings also were treatment, no differences in substance gests that smoking cessation does not increased during neutral cue exposure, use outcomes were found between increase the likelihood of relapse to suggesting that stopping one drug of patients who engaged in smoking cessa alcohol use or increase alcohol-related abuse and not another may result in tion treatment and those who did not. cravings (Hughes et al. 2003). Data cross-cue reactivity that places a person Looking at long-term abstinence from from Project MATCH, the largest alco in recovery at increased risk for relapse substances, an even more important holism clinical trial published to date, (Bobo et al. 1998; Toneatto el al. 1995). finding emerged. That is, at long-term indicates that alcohol-dependent smok follow-up, participation in a smoking ers can quit smoking cigarettes without cessation intervention provided during putting their sobriety at risk. In fact, Challenges in Treating substance abuse treatment was associ those who quit smoking during their Co-Occurring Smoking ated with a 25 percent greater likelihood participation in Project MATCH drank and Alcoholism of long-term abstinence from alcohol less than those who did not quit smoking and other drugs. Consistent with these and significantly reduced their alcohol Unfortunately, even with today’s best findings, data suggest that 1 year after intake for the 6 months after quitting interventions for tobacco cessation, treatment, smokers who participated in smoking (Friend and Pagano 2005). smokers in alcohol treatment or recov a substance abuse treatment program Similarly, Karam-Hage and colleagues ery face particular challenges to their and initiated smoking cessation on their (2005) studied smokers in alcohol cessation efforts. On average, compared own were less likely to be diagnosed as treatment and found that participants with smokers who do not abuse sub alcohol dependent and had more days who quit smoking on their own were stances, alcoholic smokers are more abstinent from alcohol and other sub more likely to report alcohol abstinence addicted to nicotine, smoke higher stances than those who started or contin at 1- and 6-months’ followup than nicotine cigarettes, smoke more per ued smoking during the follow-up participants who did not quit smoking day, and score higher on nicotine period (Kohn et al. 2003). Thus, empir (though this may be a function of dependence measures and on carbon ical evidence suggests that smoking ces lower levels of nicotine dependence). monoxide assessment (Burling and sation efforts may result in improved Not only does the preponderance of Burling 2003; York and Hirsch 1995). alcohol-related outcomes (even if those evidence suggest that smoking cessation Many smokers with alcoholism report efforts do not yield substantial smoking does not compromise alcohol abstinence, that they use smoking to cope with abstinence). but multiple studies indirectly suggest their urges to use alcohol or other drugs The mechanisms of action responsi that continued smoking may place (Rohsenow et al. 2005), so alcohol- ble for the potential benefits of smok alcohol-dependent smokers at risk for dependent smokers may have stronger ing cessation interventions provided alcohol relapse (Taylor et al. 2000). views about the benefits of continued during alcoholism treatment remain These data are consistent with laboratory tobacco use than do other smokers. largely unexplored. However, possible studies on cross-cue reactivity, which In addition, nicotine positively influ explanatory factors may include greater suggest that nicotine dependence and ences information processing among

210 Alcohol Research & Health Smoking Cessation and Alcohol Abstinence

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