Treating smoking dependence in depressed alcoholics

Alcohol Research & Health, Fall, 2006 by Nassima Ait-Daoud, Wendy J. Lynch, J. Kim Penberthy, Alison B. Breland, Gabrielle R. Marzani-Nissen, Bankole A. Johnson

Alcoholism and nicotine dependence share many neurobiological underpinnings; the presence of one drug can cause a person to crave the other. Depressive illness can complicate comorbid alcohol and nicotine dependence by exacerbating the negative affect encountered during attempts to abstain from one or both drugs. Given the morbidity and mortality associated with cigarette smoking, it is imperative to identify treatments to promote smoking cessation and address comorbid psychiatric conditions contemporaneously. Pharmacotherapeutic options demonstrating varying degrees of efficacy and promise in preclinical and clinical studies include nicotine replacement therapy (NRT), selective serotonin reuptake inhibitors (SSRIs), bupropion, varenicline, tricyclic antidepressants, and bupropion plus NRT. Topiramate has shown potential for promoting smoking cessation in alcoholics, although its safety in depressed patients has not been fully explored. The efficacy of medications for treating nicotine dependence is generally enhanced by the inclusion of behavioral interventions such as cognitive behavioral therapy. When group cohesion and social support are stressed, success rates increase among depressed smokers undergoing smoking cessation treatment. Additional treatment strategies targeting dually dependent individuals with comorbid psychiatric disorders, including special populations such as women and adolescents, await further investigation. KEY WORDS: Alcohol and tobacco; alcoholism; cigarette smoking; nicotine dependence; emotional and psychiatric depression; comorbidity; agents for alcohol and other drug (AOD) concurrent mental disorders; cessation of AOD use (AODU); smoking cessation treatment; serotonin receptors; serotonin reuptake inhibitors; pharmacotherapy; bupropion; varenicline; topiramate; tricyclic antidepressant; nicotine replacement therapy; psychotherapy; cognitive behavioral therapy

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Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States (McGinnis and Foege 1993). Fifty to 90 percent of people with mental illness or addiction also are nicotine dependent (Williams and Ziedonis 2004). Compared with the general population, alcohol-dependent or other mentally ill smokers have increased physical health consequences and mortality rates (Williams and Ziedonis 2004). Further, co-occurrence of substance abuse and depression is associated with greater impairment and worse treatment outcomes than either disorder alone (Brown et al. 2000). Therefore, smoking exacerbates the consequences of comorbid (1) substance abuse and can complicate the course of psychiatric disorders.

People who are dependent on either alcohol or nicotine often are at increased risk for the other comorbid disorder. Smokers have two to three times greater risk for alcohol dependence than nonsmokers (Breslau 1995), and about 80 percent of alcoholics also are dependent on nicotine (Hughes 1996). Indeed, recent research has suggested a neurobiological link between nicotine and alcohol dependence. For instance, alcohol and nicotine share a common neurobiological substrate involving the cortico-mesolimbic dopamine system, which is critical for expressing the positive reinforcing effects of these drugs (Hemby et al. 1997; Wise 1996). Preclinical studies also show that neurochemical interactions between alcohol and nicotine can augment the reinforcing effects of the combination (Soderpalm et al. 2000) and that the presence of one drug can trigger drug-seeking behavior for the other (Le et al. 2003).

Tobacco and alcohol seem to trigger similar central opioid peptide responses; therefore, both substances often are used as self-medication for comorbid affective disorder (Abrams et al. 1992; Hertling et al. 2005; Pomerleau and Pomerleau 1987). Thus, Currie and colleagues (2001) have suggested that people with a combined history of alcohol dependence and major depression are at high risk of using smoking as a means of mood enhancement. Craving for alcohol or nicotine is positively correlated with depression and anxiety, and alcohol-dependent patients often experience the urge to smoke in response to the discomfort associated with the urge to drink or to enhance their mood (Rohsenow et al. 1997).

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Some practitioners might be reluctant to treat nicotine dependence in mental health settings if they think that it would depress mood and increase anxiety among patients trying to overcome other addictions or mental illness. Nevertheless, despite the belief that smoking cessation can trigger alcohol relapse among people dependent on both drugs, contemporary studies show that smoking cessation treatment does not cause abstinent alcoholics to relapse (Hughes and Callas 2003). Indeed, treatment that promotes smoking cessation among smokers within an alcohol-dependent population might decrease the likelihood of relapse to drinking.

The clinical approach toward treating people with comorbid nicotine and alcohol dependence becomes more complicated among patients who also have a depressive illness. Such individuals might smoke or drink to relieve negative affective mood states such as depression and anxiety and therefore would be expected to be more difficult to treat. This article will review some of the treatments available to help patients with comorbid alcohol and nicotine dependence and depression, discuss the limitations of these treatments, and introduce some of the new treatment approaches that might lessen the challenge of treating this population.