Smoking cessation and alcohol abstinence: what do the data tell us?

Alcohol Research & Health, Fall, 2006 by Suzy Bird Gulliver, Barbara W. Kamholz, Amy W. Helstrom

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

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Cigarette smoking and alcohol dependence co-occur at high rates. Research indicates that approximately 80 percent of people with alcoholism smoke cigarettes and that most of these smokers are nicotine dependent (Hughes 1996). Conversely, smokers are at two to three times greater risk for alcohol dependence than nonsmokers (Breslau 1995).

SMOKING CESSATION AND TREATMENT FOR ALCOHOLISM

Despite the fact that 60 to 75 percent of patients in alcoholism treatment are tobacco dependent and about 40 to 50 percent are heavy smokers (Hughes 1995), treatment for tobacco dependence is not routinely included in alcohol treatment programs. Smoking cessation treatment (as well as bans on smoking) during the course of treatment for alcohol dependence has been avoided largely out of concern that concurrently addressing both addictions (or restricting smoking during treatment for alcoholism) poses too great a difficulty for the patient and would adversely affect recovery from alcoholism. Such concerns are apparent both in the United States and around the world (e.g., Walsh et al. 2005; Zullino et al. 2003). Myths surrounding concurrent treatment for smoking and alcoholism also include the ideas that smoking is a benign problem relative to alcoholism, that patients with comorbid alcoholism have either no interest or no ability to quit smoking, and that patients will relapse to alcohol if they quit smoking. This article summarizes the scientific findings that address these issues and provides evidence-based responses to common concerns about smoking cessation during alcoholism treatment.

Myth: Smoking is more benign than alcoholism. The short-term effects of alcoholism may appear more dangerous than those of cigarette smoking. However, mortality statistics suggest that more people with alcoholism die from smoking-related diseases than from alcohol-related diseases (Hurt et al. 1996). In addition, the greater prevalence of smoking in alcohol-dependent versus other populations exacerbates health risks (Bien and Burge 1990; York and Hirsch 1995). Researchers have demonstrated synergistic carcinogenic effects for dual substance dependence. For example, the relative risk of laryngeal cancer has been estimated at 2.1 in heavy smokers, 2.2 in heavy drinkers, and 8.1 in people who are both heavy drinkers and heavy smokers (Hinds et al. 1979).

Myth: Smokers with comorbid alcoholism have either no interest or no ability to quit smoking. It is interesting to note that although addiction treatment programs routinely address multiple substances of addiction (e.g., alcohol, marijuana, heroin, cocaine), tobacco is frequently the sole excluded substance. The scientific literature also frequently describes treatment of multiple nontobacco substances simultaneously, making it difficult to evaluate the impact of smoking cessation on alcoholism treatment per se (cf. Prochaska et al. 2004). Still, evidence contradicts the notion that smokers with comorbid alcoholism are not interested in quitting smoking and that addictions need to be treated one at a time (e.g., Kalman 1998). Up to 80 percent of people in addiction treatment are interested in quitting smoking (cf Prochaska et al. 2004). Consistent with this, Flach and Diener (2004) found that among dual users, approximately 75 percent wanted to quit both smoking and alcohol use (though the desire to quit alcohol use was rated as higher). Furthermore, many people entering treatment for alcoholism are willing to quit smoking (e.g., Saxon et al. 1997). In fact, one study found that 75 percent of substance-dependent inpatients accepted concurrent tobacco treatment (Seidner et al. 1996).

Inclusion of smoking as a target for intervention does not appear to reduce patients' commitment to broader addiction treatment. For example, incorporating smoking cessation treatment into inpatient addiction treatment centers has not substantially reduced long-term treatment completion (e.g., a minimal drop from 75 to 70 percent at one site) (Sharp et al. 2003). In addition, Monti and colleagues (1995) found that smoking rates actually decrease and the motivation to quit smoking increases following successful alcohol treatment.