Nicotine dependence and alcoholism epidemiology and treatment

Flavonoids as Potential Wound-Healing Molecules: Emphasis on Pathways Perspective

Wounds are considered to be a serious problem that affects the healthcare sector in many countries, primarily due to diabetes and obesity. Wounds become worse because of unhealthy lifestyles and habits. Wound healing is a complicated physiological process that is essential for restoring the epithelial barrier after an injury. Numerous studies have reported that flavonoids possess wound-healing properties due to their well-acclaimed anti-inflammatory, angiogenesis, re-epithelialization, and antioxidant effects. They have been shown to be able to act on the wound-healing process via expression of biomarkers respective to the pathways that mainly include Wnt/β-catenin, Hippo, Transforming Growth Factor-beta (TGF-β), Hedgehog, c-Jun N-Terminal Kinase (JNK), NF-E2-related factor 2/antioxidant responsive element (Nrf2/ARE), Nuclear Factor Kappa B (NF-κB), MAPK/ERK, Ras/Raf/MEK/ERK, phosphatidylinositol 3-kinase (PI3K)/Akt, Nitric oxide (NO) pathways, etc. Hence, we have compiled existing evidence on the manipulation of flavonoids towards achieving skin wound healing, together with current limitations and future perspectives in support of these polyphenolic compounds as safe wound-healing agents, in this review.

Effectiveness of Varenicline in Psychiatric Patients with Co-Morbid Polysubstance Dependence

Introduction: Individuals with substance use disorders (SUDs) and mental health disorders (MHDs) have greater prevalence of smoking and suffer greater tobacco-related morbidity and mortality. Varenicline is the latest FDA-approved smoking-cessation agent and few studies have investigated the use of varenicline in this difficult-to-treat population.

Aims: This study examines the smoking cessation outcomes and tolerability of varenicline when used to help quit smoking in 16 patients enroled in both psychiatric and substance abuse programme.

Methods: A retrospective chart review was conducted on 16 patient charts. Patient demographics, psychiatric disorder diagnoses, substance use history, dosing, side effects, number of cigarettes used pre/post varenicline use and the number of complete smoking cessation outcomes were tabulated.

Results: After varenicline intervention, 25% of those who completed treatment completely quit smoking. Thirty-one per cent were able to substantially cut back the amount that they smoked to one cigarette per day. The average reduction in cigarettes was 16 per day (64%), and all but one patient tolerated varenicline.

Conclusions: The authors observed reasonable clinical benefit when varenicline was used to help quit smoking in patients with comorbid SUDs and MHDs. Better-controlled future studies with larger sample sizes will help further determine clinical utility of varenicline in this difficult-to-treat nicotine-dependent population.

Cigarette Smoking During Substance Use Disorder Treatment: Secondary Outcomes from a National Drug Abuse Treatment Clinical Trials Network study

INTRODUCTION

The majority of patients enrolled in treatment for substance use disorders (SUDs) also use tobacco. Many will continue to use tobacco even during abstinence from other drugs and alcohol, often leading to smoking-related illnesses. Despite this, little research has been conducted to assess the influence of being a smoker on SUD treatment outcomes and changes in smoking during a treatment episode.

METHODS

In this secondary analysis, cigarette smoking was evaluated in participants completing outpatient SUD treatment as part of a multi-site study conducted by the National Drug Abuse Treatment Clinical Trials Network. Analyses included the assessment of changes in smoking and nicotine dependence via the Fagerström Test for Nicotine Dependence during the 12-week study among all smokers (aim #1), specifically among those in the experimental treatment group (aim #2), and the moderating effect of being a smoker on treatment outcomes (aim #3).

RESULTS

Participants generally did not reduce or quit smoking throughout the course of the study. Among a sub-set of participants with higher baseline nicotine dependence scores randomized to the control arm, scores at the end of treatment were lower compared to the experimental arm, though measures of smoking quantity did not appear to decrease. Further, being a smoker was associated with poorer treatment outcomes compared to non-smokers enrolled in the trial.

CONCLUSIONS

This study provides evidence that patients enrolled in community-based SUD treatment continue to smoke, even when abstaining from drugs and alcohol. These results add to the growing literature encouraging the implementation of targeted, evidence-based interventions to promote abstinence from tobacco among SUD treatment patients.

Effects of anxiety sensitivity on alcohol problems: evaluating chained mediation through generalized anxiety, depression and drinking motives

AIMS

To test whether the relations between anxiety sensitivity (AS), a transdiagnostic risk factor, and alcohol problems are explained by chained mediation models, from AS through anxiety or depressive symptoms then drinking motives in an at-risk sample. It was hypothesized that AS would influence alcohol problems through generalized anxiety or depression symptoms and then through negatively reinforced drinking motives (i.e. drinking to cope with negative affect and drinking to conform).

DESIGN

Cross-sectional single- and chained-mediation models were tested.

SETTING

Self-report measures were completed in clinics at Florida State University and the University of Vermont, USA.

PARTICIPANTS

Participants consisted of 523 adult daily cigarette smokers [mean age = 37.23, standard deviation (SD) = 13.53; 48.6% female].

MEASUREMENTS

As part of a larger battery of self-report measures, participants completed self-report measures of AS, generalized anxiety, depression, drinking motives and alcohol problems.

FINDINGS

Chained mediation was found from AS to alcohol problems through generalized anxiety then through drinking to cope with negative affect [B = 0.04, 90% confidence interval (CI) = 0.004, 0.10)]. Chained mediation was also found from AS to alcohol problems through depression then through drinking to cope with negative affect (B = 0.11, 90% CI = 0.05, 0.21) and, separately, through socially motivated drinking (B = 0.05, 90% CI = 0.003, 0.11).

CONCLUSIONS

Anxiety sensitivity and alcohol problems are indirectly related through several intervening variables, such as through generalized anxiety or depression and then through drinking to cope with negative affect.

Outcomes following treatment of veterans for substance and tobacco addiction

Persons who use tobacco in addition to alcohol and other drugs have increased health risks and mortality rates. The purpose of this study was to evaluate the impact of participation in a tobacco cessation program on tobacco, alcohol, and other drug use in a population seeking treatment for substance use disorders (SUDs). Tobacco, alcohol, and other drug use were assessed by urine drug screens, breathalyzer readings, and self-report. Veterans (N=137) with a tobacco use disorder enrolled in inpatient program for the treatment of SUDs at the Salem Veterans Affairs Medical Center participated in tobacco cessation education as part of their treatment programming. Use of tobacco, drugs and/or alcohol was evaluated upon admission, 2 weeks following admission, at discharge and 1 month following graduation. The 1-month follow-up rate was 70.8%, with 97 veterans completing the follow-up assessment. Of those 97 veterans, 90.7% (n=88) reported abstinence from alcohol and 91.8% (n=89) reported abstinence from other drugs of abuse. Fourteen veterans (14.4%) reported abstinence from tobacco at the 1-month follow-up. The veterans reporting abstinence from tobacco use also reported abstinence from alcohol and other drugs at the 1-month follow-up.

Relationships between drinking motives and smoking expectancies among daily smokers who are also problem drinkers

OBJECTIVE

There is a high co-occurrence of problem drinking and regular cigarette smoking, and cognitive processes (e.g., motivation to use, expectations about the consequences of use) related to each are positively associated with one another. We explored drinking motives in relation to cognitive-based smoking processes among smokers with problematic drinking. We expected that drinking coping motives would be associated with smoking consequences related to negative reinforcement and negative personal outcomes and inflexibility of smoking behavior; observed effects for coping motives would be unique from shared variance with other motives and incrementally evident beyond the variance accounted for by tobacco-related health problems, smoking rate, negative affectivity, cannabis use, and gender.

METHODS

The sample included 195 individuals recruited into a larger study of smoking cessation treatments (i.e., they were interested in quitting), who were heavy drinkers and smoked daily. Participants were primarily male (n = 122, 63%), fairly young (Mage = 30.3 years; SD = 12.46), and predominantly White/Caucasian (n = 175, 80%). Roughly 57% (n = 111) had at least one comorbid Axis I disorder, the most common being social anxiety (n = 21, 11%) and generalized anxiety disorder (n = 12, 6%).

RESULTS

Coping drinking motives predicted negative smoking consequences, negative reinforcement, and smoking inflexibility. Enhancement drinking motives marginally predicted positive reinforcement. Conformity drinking motives predicted smoking consequences related to appetite/weight control. Social drinking motives predicted negative reinforcement and barriers to cessation and marginally predicted positive reinforcement.

CONCLUSIONS

Theoretical models and clinical activities focused on smoking cessation among problem drinkers may benefit from considering the role of drinking motives, particularly coping-oriented motives, to better understanding cognitive-based smoking processes.

Characterizing smoking, cessation services, and quit interest across outpatient substance abuse treatment modalities

The majority of individuals seeking treatment for substance use disorders are cigarette smokers, yet smoking cessation is rarely addressed during treatment. Conducting a detailed smoking-related characterization of substance abuse treatment patients across treatment modalities may facilitate the development of tailored treatment strategies. This study administered a battery of self-report instruments to compare tobacco use, quit attempts, smoking knowledge and attitudes, program services, and interest in quitting among smoking patients enrolled in opioid replacement therapy (ORT) versus non-opioid replacement (non-ORT). ORT compared with non-ORT participants smoked more heavily, had greater tobacco dependence, and endorsed greater exposure to smoking cessation services at their treatment programs. Favorable attitudes towards cessation during treatment were found within both groups. These data identify several potential clinical targets, most notably including confidence in abstaining and attitudes toward cessation pharmacotherapies that may be addressed by substance abuse treatment clinics.

Bupropion-SR for smoking cessation in early recovery from alcohol dependence: a placebo-controlled, double-blind pilot study

We conducted a double-blind pilot study involving 11 alcohol- and nicotine-dependent patients randomized to receive either bupropion or placebo. Four of six patients on bupropion and one of five patients on placebo were abstinent from smoking at the end of medication phase. Those in the bupropion group reported significantly less craving (p < .02) and less exposure to cigarette smoke over time (expired carbon monoxide; p < .01). There were no serious adverse events and no main effects of medication group on either per subject or total number of adverse events. All those who completed treatment remained abstinent from alcohol.

Effects on substance use outcomes in adolescents receiving motivational interviewing for smoking cessation during psychiatric hospitalization

The purpose of this study was to compare substance involvement among psychiatrically hospitalized adolescent smokers who had received motivational interviewing (MI) versus brief advice (BA) for smoking cessation. One hundred and ninety-one (191) adolescent smokers (62.3% female; 15.4 years of age) were randomly assigned to MI (n=116) or BA (n=75). All patients were assessed at baseline, immediately after hospitalization, and at 1-, 3-, 6-, 9-, and 12-month follow-ups. Rates of substance use in the MI condition during follow-up increased from a low of 8.2% (SD=18.5) to a high of 15.4% (SD=30.0) substance use days, whereas in BA, substance use days increased from a low of 8.4% (SD=20.8) to a high of 21.4% (SD=35.2). The results of this study suggest that MI, relative to BA, for smoking cessation was associated with better substance use outcomes during the first 6 months following psychiatric hospitalization among adolescents. This finding is consistent with previous studies that have shown that smoking cessation does not have a detrimental effect on substance abuse treatment outcomes among youth.

Substance use, trait measures, and subjective response to nicotine in never-smokers stratified on parental smoking history and sex

INTRODUCTION

Male and female never-smokers stratified on parental history of smoking were tested for possible differences in susceptibility to the hedonic effects of nicotine.

METHODS

We recruited nicotine-exposed never-smokers with two never-smoking biological parents (PH-) or two ever-smoking biological parents (PH+). After completing a baseline assessment battery focusing on conditions or behaviors associated with smoking, participants were tested for subjective and hedonic effects in response to administration of three different nicotine doses (0.0, 0.5, and 1.0 mg) via nasal spray. Physiological and biochemical reactivity also was monitored.

RESULTS

PH+ were significantly more likely to report having experienced a "buzz" upon early smoking experimentation and to have histories of alcohol abuse and alcoholism; they also scored higher on disordered eating. In response to nicotine dosing, PH+ reported an increase in depressed mood, compared with a minimal response in PH-, in keeping with our expectation that nicotine would have more pronounced effects in PH+. Regardless of parental history, women reported experiencing greater anxiety in response to the highest nicotine dose, compared with men.

DISCUSSION

Further exploration in larger samples, using more stringent selection criteria, a wider range of measures, and a less aversive dosing method, may provide a full test of the possible utility of the parental history model for illuminating biobehavioral mechanisms underlying response to nicotine. Also important would be broadening the scope of inquiry to include comparisons with ever-smokers to determine what protected PH+ from becoming smokers, despite the presence of factors that might be expected to decrease resilience and increase susceptibility.

Substance abuse counselor certification in California: how is nicotine addiction addressed?

Persons entering substance abuse treatment smoke at rates three to four times that of the general population, but programs providing substance abuse treatment rarely address comorbid nicotine addiction. With California's recent adoption of a regulation requiring alcohol and other drug (AOD) counselors to be certified, this study explored the degree to which nicotine addiction education was required or recommended to obtain certification by examining pertinent documentation and Web sites. Findings reveal two main points. First, the text of the California AOD Counselor Certification regulation and supporting documents make no mention of cigarettes, nicotine, smoking, or tobacco, and thus do not mandate or recommend they be addressed in the counselor certification process. Second, although nicotine or tobacco were not mentioned in regulatory or supporting documents, four of the 10 certifying organizations mentioned nicotine at least once in handbooks, program books, continuing education topics, or other materials available online. One certifying organization offered specialization in smoking and nicotine addiction as separate tracks within its certification training program. While systematic inclusion of smoking and nicotine addiction in counselor training offers one strategy to address smoking in substance abuse treatment settings, these topics are not addressed in regulations or supporting documents governing the certification of California AOD counselors.

Staying in action: The pathological gambler's equivalent of the dry drunk

Alcoholics Anonymous refers to the alcoholic who has stopped drinking, but who still demonstrates alcoholic attitudes and behaviors, as a "dry drunk." Such individuals are said to have abstinence but not sobriety. They are considered at risk for relapse. Although the concept of the dry drunk has been adopted by other self-help programs, "staying in action" is an equivalent and arguably more meaningful expression to use for the understanding and treatment of many pathological gamblers. The author discusses covert gambling, mind bets, switching and fusing of addictions, procrastination, risk-taking, and power games; a repertoire of ways in which the individual can remain in a gambling mind-set while technically abstinent. This is a clinical paper, based on the author's experience, especially in treating the more traditional, action-seeking gamblers. Vignettes are utilized to illustrate various behaviors and states of mind. The emphasis is on their identification and on the need for the therapist to confront these behaviors and attitudes before they lead to relapse.

Differences between smokers and nonsmokers in regional gray matter volumes and densities

BACKGROUND

Magnetic resonance imaging (MRI) studies have demonstrated large-scale brain abnormalities in cigarette smokers, such as ventricular enlargement and atrophy. Converging lines of evidence point to functional differences between smokers and nonsmokers in specific brain regions, namely the lateral prefrontal cortex (PFC), anterior cingulate cortex (ACC), ventral striatum, and thalamus. Using MRI, we examined these regions for differences in gray matter between smokers and nonsmokers.

METHODS

Thirty-six otherwise healthy adults (19 smokers and 17 nonsmoking control subjects) underwent three-dimensional Fourier-transform spoiled-gradient-recalled acquisition MRI of the brain. Both hand-drawn regions of interest and the computer program voxel-based morphometry were used to assess group differences in regional gray matter volumes and densities, respectively.

RESULTS

Smokers had smaller gray matter volumes and lower gray matter densities than nonsmokers in the PFC bilaterally, along with smaller volumes in the left dorsal ACC and lower gray matter densities in the right cerebellum. Smokers also had negative associations between pack-year smoking history and PFC gray matter densities.

CONCLUSIONS

Smokers and nonsmokers differed in regional gray matter in brain areas previously linked with nicotine dependence. These findings might reflect effects of chronic smoking, predisposing traits that lead to smoking, or some combination of these factors.

Association of parental smoking history with nicotine dependence, smoking rate, and psychological cofactors in adult smokers

Family history is a powerful predictor of variation in risk of common diseases and conditions because it can represent the influence of both shared genes and shared environments. To investigate the relationship of parental smoking history with nicotine dependence and smoking rate, as well as with known psychological cofactors for smoking (depression, anxiety, alcoholism, disordered eating), we studied smoking adults who provided smoking history for both parents. We found that having two ever-smoking parents, in comparison to zero or one, was associated with higher nicotine dependence scores, cigarettes per day, and levels of anxiety in participant, with a trend for depression. Participants whose mothers smoked during pregnancy had significantly higher scores on nicotine dependence, smoking rate, and disordered eating than participants with either ever-smoking mothers who did not smoke during pregnancy or never-smoking mothers. These findings suggest that family history of smoking may be a key determinant of interindividual variation in smoking behavior, nicotine dependence, and psychological cofactors among smokers.

The alcohol-tobacco relationship: a prospective study among adolescents in six European countries

AIM

This study examined the earliest stages in drug involvement, in terms of the relationship between alcohol and tobacco use, among adolescents from six European countries (Denmark, Finland, the Netherlands, Portugal, Spain and the United Kingdom). International, gender and age differences were studied.

DESIGN, SETTING AND PARTICIPANTS

A large international sample of European adolescents (n = 10170, mean age = 13.3 years) was followed longitudinally. Data were gathered in the autumn terms of 1998 and 1999 by means of self-administered questionnaires.

MEASURES

Adolescents' self-reports on smoking and alcohol behaviour were used. Both behaviours were classified into two categories, that of adolescents who had never used the substance and that of those who had used the substance at least once in their lives. Logistic regression was used to determine which substance was the best predictor of the subsequent use of the other substance.

FINDINGS

Alcohol use and tobacco use were found to be associated with each other reciprocally. Results revealed that in Europe as a whole, tobacco use predicted subsequent alcohol use better than the converse. However, for Dutch girls, alcohol use predicted subsequent smoking behaviour better than the converse.

CONCLUSION

The findings suggest that the development of alcohol and tobacco use patterns are closely related, but the order of progression is not universal and may reflect cultural factors.

Effects of nicotine deprivation on urges to drink and smoke in alcoholic smokers

AIM

This study examined the effect of nicotine deprivation on alcohol and smoking urges in a sample of alcohol-dependent smokers in early recovery.

DESIGN

Using a within-subjects design, participants underwent two cue-reactivity laboratory sessions in which they rated their urges for alcohol and cigarettes during the following three trials: baseline, neutral cue and mood induction combined with alcohol beverage cue exposure. One session was completed after 34 hours of nicotine deprivation and another in a non-deprived state.

PARTICIPANTS

Forty alcohol-dependent heavy smokers recruited from a substance abuse day treatment program.

MEASUREMENTS

Self-reported urge to drink, urge to smoke and salivation.

FINDINGS

Results showed that during the non-deprived session, alcohol cue presentations were associated with significant increases in urges to drink and urges to smoke. Acute nicotine deprivation led to increased smoking urges, but was not associated with increased urges to drink alcohol.

CONCLUSIONS

Findings suggest that the acute effects of smoking cessation are unlikely to increase risk of relapse to alcohol in alcoholic patients who are undergoing treatment.

Treatment of tobacco dependence in alcoholics

Because of the high morbidity and mortality that alcoholic smokers experience from tobacco-caused diseases, treatment for tobacco dependence among alcoholics is warranted. Much progress has been made during the last decade in addressing tobacco dependence in alcoholism treatment units. Treatment of tobacco dependence in alcoholic smokers does not seem to cause excessive relapse to drinking and, in fact, stopping smoking may enhance abstinence from drinking. Therefore, treatment for alcoholic smokers should take place whenever and wherever the patient comes in contact with the health care system. Because alcoholic smokers as a rule are more dependent on nicotine than their nonalcoholic counterparts, they may need more intensive pharmacotherapy and behavioral therapy. Because many of them have experienced 12-step approaches to recovery, that same technology can be used to initiate and maintain abstinence from tobacco use. Moreover, several pharmacologic options exist to treat tobacco dependence in alcoholic smokers. However, the efficacy of several pharmacologic therapies for alcoholic smokers needs to be tested. In addition, further research is needed on effective treatments for recovering alcoholics of various racial/ethnic backgrounds.

Perceived barriers to quitting smoking among alcohol dependent patients in treatment

Little is known about the perceived barriers to quitting smoking among alcohol abusers. In addition to the usual barriers perceived by smokers, alcohol dependent smokers may have a few barriers unique to their addictive lifestyle. The Barriers to Quitting Smoking in Substance Abuse Treatment (BQS-SAT) was administered to 96 alcohol dependent smokers in residential substance abuse treatment. The BQS-SAT is designed to assess perceived barriers to quitting smoking among alcohol abusers using eleven true-false items. One open-ended item was included to gather information about potential additional barriers. The majority of respondents reported withdrawal-related barriers such as expecting to feel irritable, anxious, restless, and about half expected intolerable urges to smoke if they were to quit smoking, as most smokers do. However, concerns about effects on sobriety and needing cigarettes to cope with feeling down were also endorsed by almost half of the patients. Total number of perceived barriers was significantly related to smoking history, expected effects from smoking, and smoking temptation but was not associated with severity of alcohol use or dependence on admission. Providing corrective feedback about these barriers could be useful when addressing smoking with patients who have alcohol abuse or dependence.

Survey of smoking cessation services in Canadian addiction programs

Many alcohol and drug treatment programs now offer smoking cessation (SC) services to their clients. Little is known about the prevalence of such services in Canadian addiction programs. A telephone survey was conducted of all Canadian adult substance abuse programs with outpatient, day program, and residential treatment to determine: (a) whether the program offered help in quitting smoking; (b) the type of SC services; (c) the overall priority placed on quitting smoking; and (d) for residential programs, what type of smoking ban (indoors, outdoors, or both), if any, is imposed. Over half (54%) of the 223 programs that responded to the survey reported providing help in quitting smoking. Twenty-three programs had formal SC services, most often in the form of group treatment. The majority of programs surveyed stated their program placed 'very little' emphasis on smoking. Smoking was relatively unrestricted in residential programs. The implications of these findings for substance abuse treatment are discussed.

Drinking and problem drinking in US women. Patterns and recent trends

General population surveys suggest that the percentage of US women who drink declined slightly during the 1980s. Comparisons of 1981 and 1991 national surveys using the same drinking measures show that fewer women drank heavily in 1991, and women drinkers drank less frequently and had fewer episodes of heavy drinking, although younger drinkers reported more frequent intoxication. Longitudinal analyses of 5-year changes in drinking behavior indicate that movement both into and out of problem drinking is greatest among women aged 21 to 34. Subgroups of women with elevated rates of heavy drinking and/or adverse drinking consequences include younger women; women lacking social roles or occupying unwanted social statuses; women in nontraditional jobs; cohabiting women; and ethnic minority women experiencing rapid acculturation. Risks of heavy and/or problem drinking are also greater among women with a heavy-drinking husband or partner; depression; sexual dysfunction; or violent victimization in childhood or adulthood. Future research should focus on (1) the causes and consequences of recent declines in women's drinking; (2) antecedents and consequences of specific patterns of multiple substance use in women; (3) social and relational contexts of women's drinking, including occupational influences, drinking behavior of significant others, sexual dysfunction, and relationship violence; (4) longitudinal predictors of both problem drinking onset and "spontaneous" remission of women's alcohol problems; and (5) childhood sexual abuse as a potentially powerful risk factor for later alcohol abuse in women.

Effect of current tobacco use and history of an alcohol problem on health status in hospitalized patients

This prospective study assessed the relationship between current tobacco use and history of an alcohol problem to health status in hospitalized patients. Factors associated with current tobacco use and history of an alcohol problem were also evaluated. Data were collected using a self-administered survey distributed by nursing staff to adult inpatients registered on April 27, 1994 at the Mayo Clinic, Rochester, Minnesota affiliated hospitals. Respondents (N = 589, 45% female) were classified into 4 subgroups based on current tobacco use status and history of an alcohol problem: (a) current tobacco use only (n = 94, 16%); (b) history of an alcohol problem only (n = 30, 5%); (c) both (n = 27, 5%); or (d) neither (n = 438, 74%). Patients with both current tobacco use and an alcohol problem history reported markedly lower scores on health status measures of general and mental health compared to the other three subgroups. Moreover, current tobacco use and history of an alcohol problem were each associated with increased psychological distress. Current tobacco use was predictive of a history of an alcohol problem and vice versa.

Tobacco cessation with patients recovering from alcohol and other substance abuse

This article focuses on the problem of tobacco cessation in the patient recovering from alcohol or other substance abuse. The authors review the epidemiology of the problem, specific health risks to this population from continued tobacco use, and recent research findings that address previous treatment concerns. Recommendations for counseling by physicians are made. These include an algorithm for determining the patient's stage of readiness for making a quit attempt, specific counseling tasks based on the patients stage, and motivational counseling strategies aimed at increasing the patients motivation to quit.

Effect of counselor and client education in nicotine addiction on smoking in substance abusers

Smoking cessation has received little attention in substance abuse programs. The present study analyzed the effect that counselor and client education in nicotine addiction had on clients' treatment readiness for a smoking cessation program. Thirty-eight smoking clients and two counselors from a short-term residential alcohol treatment facility participated in this study. Counselors served in both the treatment and control conditions in this 2x2 mixed factorial design by first participating in the control condition (general substance abuse education) and then in the treatment condition (smoking education). Counselors proceeded to work (for 6 weeks) with clients who had participated in the control education in general substance abuse issues and with clients who participated in the treatment education series in smoking issues. Clients completed the Fagerstrom Test for Nicotine Dependence and Stages of Change Ladders pre- and posttest. Results indicated that counselor and client education was effective in significantly changing the clients' thoughts toward smoking cessation and their smoking behaviors. Implications for instituting a smoking education program involving counselors, as well as clients, are discussed.

Smoking cessation following treatment in a smoke-free Navy Alcohol Rehabilitation program

The purpose of this study was to examine changes in smoking behavior and attitudes following treatment in the smoke-free Navy Alcohol Rehabilitation program (NARC) and to evaluate changes in staff attitudes toward the smoke-free policy. Consecutive patients (N = 404; 93.8% male) admitted to the NARC between February 1, 1993 and September 30, 1993 were studied, of whom 54.7% were current smokers. Measures included patient surveys administered repeatedly at admission and discharge and at 12 months following the 4-week treatment program. The staff were also administered a survey 2 months before (N = 86) and 6 months after (N = 104) policy implementation. Results indicate that alcohol treatment in a smoke-free environment did not markedly affect the smoking status of patients; the proportion of current smokers at discharge was 54.7%. Significant reductions in cigarettes smoked per day (p < .001) were observed among patients from admission to discharge. However, no statistically significant change in readiness to consider smoking cessation scores was detected. Results indicated no significant change in patient smoking status at 12-month follow-up, although the survey response rate was low (35.1%; N = 142). Six months following implementation of the smoke-free policy, 84.6% of staff indicated that the NARC should remain smoke-free and 84.6% recommended that other alcohol and drug treatment facilities be smoke-free.

Predictors of relapse to heavy drinking in alcohol dependent subjects following alcohol detoxification-the role of quality of life measures, ethnicity, social class, cigarette and drug use

Sixty DSM-IV alcohol dependent adults (39 males, 21 females) admitted to a voluntary sector alcohol detoxification unit in South London were studied. Socio-demographic data and information on level of alcohol dependence, quality of life, family history, cigarette smoking and the use of prescription/illicit drugs were collected. The subjects were followed-up at 12 weeks and subdivided into two groups, relapse and non-relapse. A relapse was defined as drinking 21 units or more per week for males and 14 units or more per week for females. Data were analysed for baseline and 12-week follow-up comparisons. At 12 weeks, 58 (97%) subjects (38 males, 20 females) were successfully followed-up and 36/58 (62%) had relapsed. After controlling for a Type I error there were significant differences between the relapse and non-relapse subgroups at 12-week followup on the following outcome measures; depression, life situation, withdrawal symptoms, energy, emotional reactions and social isolation. There were no significant differences at baseline between the relapse and nonrelapse subgroups for most of the socio-demographic variables, but Irish nationality and membership of lower social classes (IV and V) were associated with relapse. Major predictors of relapse at baseline after a forward stepwise logistic regression were (in order of increasing statistical significance) Irish nationality, lower social class, greater number of cigarettes smoked and disturbed sleep. The findings are discussed with reference to their consistency with existing research and potential clinical implications.

Smoking cessation for clients in chemical dependence treatment. A demonstration project

A demonstration project was conducted to examine the factors that facilitate implementation of nicotine dependence treatment in a chemical dependence (cd) program. The project included: (a) staff education; (b) staff training to conduct nicotine dependence treatment groups; (c) voluntary smoking cessation treatment for smoking staff; and (d) smoking cessation treatment for client volunteers in outpatient and residential cd programs. A 12-week, cognitive/behavioral group program with nicotine patches was conducted separately for staff and client volunteers. Forty-two of approximately 70 staff returned smoking questionnaires, 10 of whom reported current smoking. Four staff members began treatment, in addition to four staff from a second treatment agency. There were three of eight staff (37.5%) who reported ongoing abstinence at the end of the 12-week program. There were 83 cd clients (approximately 20% of smoking clients) who volunteered to participate in smoking cessation treatment. Forty clients began treatment, 3 (7.5%) of whom were abstinent from smoking at the conclusion of the 12-week program. Staff smoking, lack of clinic resources devoted to the project, and voluntary client participation, which was adjunctive to other treatment components, were impediments to implementation and success. Success was greatest in a clinical setting in which smoking cessation treatment was staff supported and integrated with cd treatment. We recommend that (a) smoking cd staff be offered nicotine dependence treatment, (b) nicotine dependence treatment become a standard, integrated component of cd treatment, and (c) initiation of smoking cessation be individualized according to clients' needs and circumstances.

Incorporating nicotine dependence into addiction treatment

An addiction treatment program devoted two years to preparing to become a smokefree treatment unit that addressed nicotine dependence as another drug dependency. Data collected from September 1990 to July 1995 on 263 admissions before becoming smokefree and 2182 admissions after making the transition revealed that going smokefree did not affect the incidence of premature discharges or aggressive behavior, and did not change the overall rate of program completion by either smokers or nonsmokers. During the first three months after going smokefree, the program completion rate dropped for both smokers and nonsmokers; by the fourth month, it had returned to previous levels. Seventeen months after going smokefree, the program completion rate was higher than it had ever been. This suggests that the drop in the program completion rate was due to the disruption caused by a significant programmatic change and not due to the unit's smokefree status, and that the increasing experience of staff in treating nicotine dependence resulted in improved patient outcomes.

Issues related to smoking cessation among substance abusers

Initial studies have found that stop-smoking treatments for newly recovering substance abusers have been neither harmful to sobriety nor effective in achieving smoking cessation. The development of more effective stop-smoking treatments for this population could be aided by delineating their particular smoking-related characteristics. This article describes the biopsychosocial characteristics of newly recovering substance abusers that are relevant to smoking cessation, and suggests that there are notable differences between abusers and nonabusers that may contribute to abusers' greater difficulty in quitting smoking. It also recommends changes in existing treatment protocols where applicable and identifies key areas for future research.

A preliminary analysis of the perceived risks of misusing multiple substances, trait anxiety, and approval motivation

In a sample of college undergraduates, perceptions of the risks associated with the misuse of substances such as alcohol, cigarettes, and marijuana were evaluated, and the correlations of risk ratings with trait anxiety and approval motivation were examined. The results indicated (a) a temporally stable, hierarchical ordering of risk means that ranged from illicit to licit substance pairs; (b) a string negative correlation between perceived risk means and corresponding standard deviations, suggesting that greater variability was associated with lower perceived risk; (c) small to small/moderate correlations between high risk ratings and trait anxiety; and (d) small to small/moderate correlations between risk ratings and approval motivation. These findings provide a first approximation of young adults' perceptions of the possible risks involved in the misuse of multiple substances and suggest that such perceptions are not confounded by dispositional anxiety of by social desirability response bias. The results discussed in light of their implications for alcohol and drug education.

Gender differences in alcohol and other drug use among young adults

This article describes gender differences in alcohol and other drug (AOD) use and misuse in a representative sample of young women and men in the United States. Data were drawn from the National Longitudinal Survey of Youth (NLSY) and focus on gender differences in prevalence and patterns of AOD use in African American, Hispanic, and White young adults ages 19 to 24 years old. Findings are summarized and implications for prevention are presented.

Can psychiatric and chemical dependency treatment units be smoke free?

The feasibility and appropriateness of establishing smoke-free psychiatric and chemical dependency treatment units are topics of recent interest. This paper reviews the literature on the implementation of smoke-free policies in psychiatric and chemical dependency treatment units. Several issues are addressed including (a) the concerns raised by treatment staff regarding the implementation of a smoke-free policy, (b) the effects of involuntary smoking cessation or reduction on the treatment and/or recovery of patients, (c) the utilization of smoking cessation interventions by patients and staff, and (d) the effects of a smoke-free environment on the smoking behavior of patients and staff. It is concluded that a smoke-free environment is a reasonable and achievable goal in these settings. However, the implementation of a smoke-free policy in chemical dependency treatment units has met with several more problems than those observed in psychiatric settings. Recommendations for further clinical research and program implementation are offered.

Predictors of tobacco quit attempts among recovering alcoholics

Reported here are findings from a randomized community intervention trial that followed 90 recovering alcoholic smokers for 6 months. Because the brief (10-min) study intervention had no effect on tobacco use, intervention and control participants were pooled to identify predictors of attempts to quit smoking that may inform clinical practice. During the first 6 months after discharge from residential alcohol treatment, 31% of all participants reported having quit smoking for 48 hrs or longer. Demographic and drug use history variables did not predict quit attempts, but two baseline tobacco use variables did, specifically the Fagerstrom Test for Nicotine Dependence and stage of readiness to quit smoking, p < .01. Participants with high or very high nicotine dependence scores were significantly less likely than those with moderate or low scores to attempt smoking cessation. Compared to those in precontemplation at baseline, those in the preparation stage of readiness to change were about 12 times more likely to make a serious quit attempt.

Treating cigarette smoking in drug-abusing clients

Clients in substance abuse treatment are at high risk for smoking-related illness due to higher rates and heavier smoking than the general population. Three myths widely held by both treatment staff and substance abusers in treatment-people in treatment do not want to quit smoking, people in treatment will relapse to other drug use if they attempt to quit smoking, and people in treatment are unable to quit smoking-make it difficult to broach the matter of smoking cessation. A 16-week, cognitive-behavioral group program with nicotine patches was conducted at Oregon's largest, private, nonprofit substance abuse treatment agency. Of 490 clients, approximately 85% of whom smoke, 106 (25% of the smokers) were interested enough in quitting to attend an orientation. Approximately 40% of these were methadone maintenance clients. The others were distributed among two residential and two outpatient drug-free treatment services. Of 90 assigned, 68 began voluntary treatment, and 21 were assigned to delayed treatment. Of the 66 smokers who began, 74% succeeded in quitting smoking for at least 1 day, and 23% were abstinent for at least 4 continuous weeks. At the end of the 16-week treatment, 7 subjects (11%) were abstinent. No control subjects quit smoking on their own. The article discusses issues of institutionalizing smoking cessation services in drug treatment agencies.

Effect of cigarette smoking on alcohol treatment outcome

Although smoking cigarettes and drinking alcohol are highly correlated, little research has examined the effects of smoking on alcohol abusers' posttreatment functioning. Alcohol abusers (N = 155) were classified on the basis of their pretreatment smoking status as: nonsmoker, ex-smoker, low dependent smoker (first cigarette of the day > 10 minutes after waking), and high dependent smoker (first cigarette of the day < or = 10 minutes after waking). All subjects had received brief cognitive-behavioral outpatient treatment for their alcohol problem. Subjects who were less dependent on nicotine had fewer drinking days and fewer heavy drinking days prior to entering treatment than those who were more dependent on nicotine; the two nonsmoking groups had fewer abstinent days than the low nicotine-dependent subjects and fewer heavy drinking days than the high nicotine-dependent subjects. At the 1-year follow-up, the two smoking groups did not differ from each other on the alcohol variables but reported significantly more abstinent days than the two nonsmoking groups. Treatment implications are discussed.

Measuring the stages of change in cigarette smokers

This article describes preliminary reliability testing of an instrument for measuring a smoker's progress toward abstinence or relapse. We have developed a set of visual-analog scales intended to measure subtle changes in the smoking cessation process. These are based on the Stages of Change described by DiClemente and Prochaska and the presentation format suggested by Biener and Abrams. In this study, we presented the scales in two different formats (projected on a screen using an overhead projector or printed on sheets of paper) to 23 subjects, all inpatients in a chemical dependency treatment program. The subjects' response on the two modalities were highly correlated, indicating reliability of the scale between modalities and within the time frame studied. We offer this instrument as an inexpensive and efficient means of evaluating smoking cessation strategies and the progress of individuals in smoking cessation programs.

Treatment of smoking cessation in smokers with past alcohol/drug problems

A review of existing scientific studies suggests (1) smoking is very common among alcoholics, (2) many recovering alcoholics die from smoking-related diseases, (3) recovering alcoholics are interested in smoking cessation, (4) recovering alcoholics can stop smoking, (5) smoking cessation does not appear to increase relapse to alcohol, and (6) possible treatments for smoking cessation among alcoholics have not been empirically tested. In a prior study of ours on nicotine gum, the 38 subjects (12% of the sample) who self-reported a past but not present history of alcohol/drug problems appeared more dependent on nicotine, were less likely to stop smoking (1 year quit rates = 7 vs. 19%) but appeared to benefit more from nicotine replacement therapy (+10 vs. +1% increase in 1 year quit rates with nicotine vs. placebo gum) than subjects without this history. Although these results are preliminary, they suggest recovering alcoholics might benefit from nicotine replacement therapy.

Cigarette smoking cessation and alcohol treatment

Cigarette smoking is common among problem drinkers and recovering alcoholics but most cessation research has not addressed this special population of smokers. Confidential survey data were collected from over 700 alcoholism counselors and medical personnel in residential and outpatient chemical dependency units (CDUs) in Nebraska to identify the quit smoking method these experts recommend and to assess their personal experiences with smoking cessation. A total of 334 respondents (45% of the group) self-identified as a recovering alcoholic, 51 (7%) as a problem drinker, and 350 (48%) as having no history of alcohol problems. Over 63% of all respondents were former or current smokers. The most frequently recommended quitting methods for people still in treatment for alcohol problems were relying on a support group (69%), adhering to Alcoholics Anonymous (AA) principles (64%), and quitting "cold turkey" (45%). In an adjusted logistic regression model, quitting "cold turkey" and relying on the principles of AA significantly increased a respondent's odds of personally becoming a successful tobacco quitter. We conclude that many recovering alcoholics and problem drinkers can successfully quit smoking and should be encouraged to use abstinence coping skills learned in alcohol treatment.

A smoke-free chemical dependency unit. The Cleveland Clinic experience

An attempt to eliminate smoking from the CCF chemical dependency unit resulted from an institutional mandate that the campus be smoke-free. Initially, patients were given the option of either not smoking or smoking outside with staff supervision. Those who opted for smoking cessation received no specific treatment for nicotine addiction, but were only given snacks, therapeutic activities, and stress management techniques to aid in their effort. The initiative failed. Patient and staff resistance, hazardous conditions due to surreptitious smoking, and interference with other treatment components led to suspension of the policy. A second attempt, thought to be a superior design, included therapeutic interventions similar to traditional addiction treatment; however, it also failed to produce nicotine recovery in most patients. It was noted that patients with such adverse consequences from nicotine as emphysema or cancer could be motivated to recover from nicotine addiction and were helpful in motivating those without consequences to stop smoking. Significantly, despite several patients' refusal to enter or continue in treatment due to the no smoking policy, unit census actually increased.

Recovering staff and smoking in chemical dependency programs in rural Nebraska

The problem of cigarette smoking among those who are recovering from alcohol dependence is becoming more apparent as chemical dependency units (CDUs) are beginning to restrict smoking for clients and staff and more actively encourage nicotine abstinence. To date, little is known about effective smoking cessation techniques for people with a history of alcohol problems. To obtain new data, a survey of personal experiences with smoking cessation and professional recommendations about nicotine dependence was administered to 124 recovering treatment professionals in CDUs in rural Nebraska. Among the 99 staff with a history of smoking, 81 (80%) had tried to quit smoking and 38 were former smokers at the time of the survey. Quitting "cold turkey" was the most popular smoking cessation method. Reliance on AA principles was second. The results suggest that recovering staff can successfully quit smoking by applying their professional practice guidelines for alcohol treatment to their personal problems with tobacco.

Towards a broader view of recovery

It is estimated that tobacco use accounts for 25% of the total economic cost of illness in America. Chemically dependent patients have a smoking rate that ranges from 80% to 95% in different studies, almost triple the national average. Despite these staggering statistics, only a handful of chemical dependency treatment programs treat nicotine as an addictive drug and actively encourage their patients to quit. Denial by treatment staff and fears in the Recovery community that Recovery would be jeopardized by quitting are two factors contributing to the reluctance to develop smoke-free programs and treat nicotine dependence. The fear that patients would refuse admission to a facility that prohibits smoking and resistance from staff who smoke appear to be the major barriers to adopting a smoke-free policy. The time has come to face the burdensome costs of tobacco use and to address nicotine dependence in chemical dependents. It is time to develop a broader view of Recovery.

When to begin smoking cessation in substance abusers

During the past several years, there has been an increasing recognition and acceptance that the use of tobacco products often produces nicotine dependence and nicotine addiction. Despite this, the substance abuse treatment community has been slow to promote smoking cessation for patients who are in substance abuse treatment for another addiction. Dogma, although starting to change, persists that cigarette smoking pales in comparison to other addictions and should not be addressed at the time of initial treatment for another addiction. The limited research to date, which will be reviewed in this article, does not support this dogma. In addition, patients presenting for substance abuse treatment report high interest in stopping smoking, including interest in stopping when they initially present for substance abuse treatment.

Cigarette smoking and methadone dose levels

Cigarette smoking has been shown to increase consequent to the acute administration of methadone. This suggests the possibility that differences in maintenance dose levels might be associated with differential smoking rates. It is of special concern that higher maintenance levels of methadone may lead to more cigarette smoking because of the putative beneficial effects of higher doses on illicit drug use, treatment retention, and the like. Two experiments were conducted to test the hypothesis that higher maintenance doses of methadone are related to more cigarette smoking. Smoking was measured by self-report and expired carbon monoxide, and the amounts were correlated with subjects' methadone dose levels. The results showed smoking rates of 85% and that self-reported smoking significantly correlated (r = -.52) with CO. Maintenance doses, however, were not correlated with smoking levels. This suggests that the acute effects of methadone on smoking are nullified as clients habituate to dose level, and that decisions regarding appropriate methadone dosage can be made on other grounds.

Drug use and cigarette smoking in applicants for drug abuse treatment

Whereas smoking rates have declined in the last three decades from around 40% to under 30%, the rates for substance abuse clients remain at a plateau almost three times as high. In order to examine the relations between nicotine and drug use, applicants for drug abuse treatment were surveyed about their cigarette smoking. Results indicated that 85% of applicants were smokers. Also, it was found that for smokers, frequency and type of drug use were associated with amount of cigarette use. Among the five categories of primary drugs surveyed, heroin users had the highest levels of smoking. Additionally, frequency of primary drug use and frequency of overall drug use correlated with cigarette smoking. Within categories of primary drug, frequency of use was related to severity of nicotine dependence for marijuana only. Given the possible association between severity of illicit drug use and smoking found in this study, it behooves treatment organizations to help clients overcome their nicotine dependence.