Tobacco cessation treatment for alcohol-dependent smokers: when is the best time?

Alcohol Research & Health, Fall, 2006 by Molly Kodl, Steven S. Fu, Anne M. Joseph

Cigarette smoking is highly prevalent among people with alcohol use disorders. Although several studies have demonstrated the feasibility of treating nicotine dependence in people with substance use disorders, researchers and clinicians continue to debate whether nicotine dependence treatment should be delivered simultaneously with or subsequent to alcohol treatment. Evidence suggests that alcohol-dependent individuals prefer sequential treatment and that simultaneous treatment can negatively impact alcohol use outcomes, although the literature is not conclusive. This review includes recommendations of considerations for treatment timing decisions and future research directions. KEY WORDS: Alcohol and tobacco; alcohol and other drug (AOD) use, abuse, and dependence; cigarette smoking; nicotine dependence; smoking cessation treatment; treatment outcomes; concurrent treatment; co-treatment; intervention; cessation of AOD use (AODU)

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Cigarette smoking is highly prevalent among people with alcohol abuse and dependence (i.e., alcohol use disorders) (Hughes 1996). Rates of current smoking range from 35 to 44 percent in population-based studies of adults with alcohol use disorders (Grant et al. 2004; Lasser et al. 2000) and may reach 80 percent in treatment-seeking populations (Hughes 1995). In addition, current alcohol use problems are associated with higher levels of nicotine dependence and a lower likelihood of smoking cessation (Breslau et al. 1996; Hays et al. 1999). Given the increased tobacco-related mortality and morbidity in alcohol-dependent smokers (Hurt et al. 1996) and the enhanced difficulty quitting smoking, identifying the most effective treatments and the optimal timing for treatment is critical.

Researchers and clinicians continue to debate the advisability of simultaneous nicotine and alcohol dependence treatment compared with postponing smoking treatment (Hurt and Patten 2003; Sussman 2002). Theoretical arguments against simultaneous treatment include the possibility that concurrent intervention could be detrimental to alcohol treatment outcomes (Bowman and Walsh 2003; Joseph et al. 2004b; Kalman 1998). Another frequently cited reason to avoid concurrent treatment is the belief that alcohol users do not want to quit smoking (Kalman 1998). This article reviews the evidence regarding the effects of smoking cessation treatment on alcohol treatment outcomes and the merit of simultaneous tobacco treatment versus sequential treatment for alcohol-dependent patients. A detailed review of individual studies is beyond the scope of this article, and we refer readers to Prochaska and colleagues (2004), Hughes and Kalman (2006), Hurt and Patten (2003), Kalman (1998), and Sussman (2002) for comprehensive summaries.

SUBSTANCE-DEPENDENT SMOKERS' PERSPECTIVES ON SMOKING CESSATION

Early studies suggested that a minority of people in treatment for alcohol or other drug abuse were interested in smoking cessation (Kozlowski et al. 1989; Monti et al. 1995; Orleans and Hutchinson 1993). As national interest in smoking cessation has grown, however, more smokers in substance abuse treatment are considering quitting smoking (Ellingstad et al. 1999; Rohsenow et al. 2005). Several studies have found that alcohol-dependent smokers express a preference for sequential, rather than simultaneous, tobacco treatment (Ellingstad et al. 1999; Kozlowski et al. 1989; Monti et al. 1995; Orleans and Hutchinson 1993; Rohsenow et al. 2005). This may be especially true for alcohol-dependent smokers who rely on smoking to help them to cope with urges to drink (Sussman 2002).

Other studies suggest that alcohol-dependent smokers are not opposed to concurrent smoking cessation treatment. Asher and colleagues (2003) found that fewer than half of alcohol-dependent smokers believed that quitting smoking would make it harder to maintain sobriety, and only 13 percent believed that if they quit smoking, they would be unable to manage urges to drink or use drugs. Despite this, lack of opposition to simultaneous treatment may not be synonymous with willingness to participate in concurrent smoking cessation treatment (Campbell et al. 1998). Overall, individual preferences regarding treatment timing may depend on the degree of relatedness of smoking and drinking behaviors (Ellingstad et al. 1999; Rohsenow et al. 2005; Sobell et al. 1995). For example, Ellingstad and colleagues (1999) found that patients interested in concurrent treatment, compared with those who preferred to address alcohol dependence first, were more likely to believe that quitting cigarettes would help them to resolve their drinking.

TREATMENT OUTCOMES FOR ALCOHOL-DEPENDENT SMOKERS

There are two important issues to consider regarding smoking intervention for alcohol-dependent smokers: effects on smoking behavior (i.e., abstinence from tobacco) and effects on alcohol treatment outcomes (i.e., abstinence or reduction of alcohol use). This section will review studies of tobacco cessation and substance abuse treatment among people with concurrent smoking and substance abuse, first reviewing studies of concurrent treatment, followed by studies of sequential treatment. For tobacco cessation outcomes among people with prior alcohol use, see the Textbox.