Smoking cessation
in alcohol and
other drug users
DANA Many Faces of Addiction Forum
13 August 2015
Dr Colin Mendelsohn
MB BS Hons (Syd Uni)
Tobacco Treatment Specialist
The Sydney Clinic
22-24 Murray Street
Bronte NSW 2024
[email protected]
www.colinmendelsohn.com.au
Disclosure
Payments for teaching, consulting and travel from
 Pfizer Australia Ltd
 GlaxoSmithKline
 Johnson & Johnson Pacific
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Smoking cessation for alcohol and other drug users
Some key questions
 Will quitting smoking compromise recovery from other
substance treatment?
 Should smoking be treated at the same time as other drugs
or delayed?
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Is smoking really a priority in substance users?
Does smoking reduce stress?
Can drug users quit smoking?
Is different treatment needed for smokers with SUDs?
Smoking cessation for alcohol and other drug users
Prevalence of smoking in SUD
 Australian smoking rate
15.8% (aged 14+) 1
 Substance users
– 73% in the community
– 74-98% in treatment
settings 3,4
2
 Alcohol dependence
– 61%
1. AIHW. National Drug Strategy Household Survey. 2013 2. National survey of mental health and wellbeing:
ABS, 2008 3. Guydish J. Nicotine Tob Res 2011 4. Baker A. Drug Alc Rev 2012
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Smoking cessation for alcohol and other drug users
Alcohol and other drug users
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Start smoking at a younger age
Smoke more heavily
Are more nicotine dependent
Have more difficulty quitting
Smoking cessation for alcohol and other drug users
Why are smoking rates
so high in patients with SUDs?
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Psychiatric comorbidity common
Self medication of psychiatric symptoms
Common genetic vulnerability
At-risk personality types: rebellious, low self esteem
Smoking is a gateway to harder drugs
Pharmacological interactions between drugs, increasing
reinforcing effects
 Smoking culture in drug-using social groups
Kalman D. Am J Addict 2005
6
Smoking cessation for alcohol and other drug users
Mortality from drug use
 Tobacco causes far greater
mortality (and morbidity)
than alcohol, illicit drugs and
suicide combined 1
Illicit drugs
9% of deaths
n=1,705
Alcohol
6% of deaths
n=1,084
Smoking
85% of drug deaths
n=15,511
1. Begg S. The burden of disease and injury in Aust 2003. AIHW 2007
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Smoking cessation for alcohol and other drug users
Why is it so hard to quit?
Success is elusive
 75% of Australian smokers WANT to quit 1
 40% try to quit at least once each year 1
 The average 40 year old smoker has tried 20 times to quit 1
 Unaided quit rate is 3-5% at 6-12 months 2
 Even after 6 months, 50% of smokers relapse 3
1. Cooper J. ANZJPH 2011. 2. Hughes JR. Addiction 2004 3. West R. Eur Respir Rev 2008
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Smoking cessation for alcohol and other drug users
Smoking is a drug addiction
 Nicotine dependence is a substance
use disorder 1,2
 Nicotine activates the mesolimbic
dopaminergic system, the common
pathway for drugs of addiction
 Powerful genetic factors 3
 Learned associations and cue-induced
triggers
 The most difficult drug to give up 4
1. DSM-V 2013 2. WHO. IDC 1992 3. Sullivan P. Nic Tob Res 1999 4. Kozlowski J. JAMA 1989
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Smoking cessation for alcohol and other drug users
A new paradigm
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Smoking is an addiction not a lifestyle choice
Smokers have lost control of their behaviour
Empathic, non-judgemental, supportive approach
Most smokers need help to quit
Many need repeated assistance to quit
Smoking cessation for alcohol and other drug users
Smoking neglected
in SUD treatment setting
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Urgency of other drug presentations
High staff smoking rates
Lack of staff training
Historical and cultural factors
Smoking with clients for therapeutic relationship
Myths about smoking and drug use…
Schroeder SA. Confronting a neglected epidemic. Cessation for mental illness and SUDs. Annu Rev
Pub Hlth 2010
12
Smoking cessation for alcohol and other drug users
6
myths about
smoking and
substance use
13
1
Smokers in substance use
treatment do not want to quit
 Fact. They are as motivated to quit as the
general population
 40% to 80% are interested in quitting smoking
 Many have tried to quit repeatedly
 Have often have made a serious attempt to quit within the
last year
1. Richter KP. Subst Abse Treat Prev Policy 2006 2. Hall SM. Annu Rev Clin Psychol 2009 3. Cookson C. BMC
Health Serv Res 2014
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Smoking cessation for alcohol and other drug users
2
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Smokers in substance use
treatment cannot quit
Fact. They can quit smoking
– But have lower quit rates
– May need more intensive treatment
 Quit rates
– Stimulants: 13% at 6m 1
– Alcohol dependence: 12% at 12m
– Methadone: 4-5% at 6m 2
2
 Best practice interventions in general population 22-32% 3
1. Winhusen TM. J Clin Psychiatry 2013 2. Richter KP. Subst Abuse Treat Prev Policy 2006
3. Treating Tobacco Use and Dependence. US Guidelines 2008
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Smoking cessation for alcohol and other drug users
3
Quitting will compromise
recovery from other drugs
 Fact. Smoking cessation improves recovery from
alcohol and other drugs
 Quitting during other drug treatment improves outcomes 1,2
 Smokers who quit within 1 year of substance abuse treatment
were 2.4x more likely to be abstinent up to 9y > treatment 3
1. Prochaska JJ. J Consult Clin Psychol. 2004 2. Baca C. J Subs Abuse Treat 2009 3. Tsoh JY. Drug
Alc Depend 2011
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Smoking cessation for alcohol and other drug users
4
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Treat the primary addiction
first and smoking later
Fact. The majority of evidence supports
concurrent treatment for tobacco and other
substances 1
 25% increase in abstinence from alcohol and illicit drugs, 12
months after concurrent treatment 1
 Many opportunities lost if treatment is delayed 2
1. Prochaska JJ. J Consult Clin Psych 2004 2. Joseph AM. J Stud Alcohol 2004
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Smoking cessation for alcohol and other drug users
5
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Smoking is a low priority
Fact. Smokers are more likely to die from a
tobacco-related illness than their primary drug
 Patients in inpatient addiction treatment
Other
at 11y follow-up (n=845) 1
15%
– 51% died from smoking-related disease
 Every year of smoking >35y shortens
life expectancy by 3 months
Alcohol
2,3
1. Hurt R. JAMA 1996 2. Doll R. BMJ 2004 3. Jha P. NEJM 2013
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Smoking cessation for alcohol and other drug users
34%
Tobacco
51%
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Smoking relieves stress
 Fact. Smoking appears to benefit stress but
actually increases it
 After quitting, smokers have
– Significantly improved mood, reduced anxiety and enhanced
psychological health 1
– Significantly mproved quality of life (overall life satisfaction)
Mental and physical health, social functioning, emotional
wellbeing, less pain, enhanced self control 2
1. Taylor G. BMJ 2014 2. Goldenberg M. Am J Addict 2014
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Smoking cessation for alcohol and other drug users
‘I smoke to relax’
 Relief of nicotine withdrawal confused with relaxation 1
1. Parrott A. Human Psychopharm 2012
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Starting the conversation
Relief of ‘stress’
Hmmm…
Stress is
relieved by a
cigarette
Stress of
nicotine
withdrawal
I still
feel
stressed
Real stress
Perkins KA. Acute negative affect relief from smoking depends on the
affect measure and situation, but not on nicotine. Biol Psychiatry 2010
21
Smoking cessation for alcohol and other drug users
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How to help your patients stop smoking
How to help smokers quit
2 intervention pathways
AAR
referral
pathway
ASK
REFER
Ask all patients if they smoke
Advise behavioural support and
drug treatment and offer referral
• Quitline 137 848
• GP
• Tobacco Treatment Specialist
www.aascp.org.au
ADVISE
Advise all smokers to quit
5As
treatment
pathway
ASSESS
1. Readiness to quit
2. Nicotine dependence
ASSIST
1.
2.
3.
4.
5.
Psycho-education
Plan coping strategies
Discuss barriers to quitting
Pharmacotherapy
Set a Quit Date
ARRANGE
Arrange follow up visits
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Supporting smoking cessation: a guide for
health professionals. RACGP 2014
Smoking cessation for alcohol and other drug users
1 ASK | Do you smoke?
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Do you smoke?
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A brief smoking history
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Cigarettes per day, years of smoking
Previous quit attempts
What worked?
Current medications
Smoking cessation for alcohol and other drug users
2 ADVISE | Advise all smokers to quit
 Advise all smokers to quit in a clear, personalised,
non-judgemental way
 ‘Quitting is the best thing you can do for your health. You
will be less anxious and it will be easier to abstain from
alcohol’
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Smoking cessation for alcohol and other drug users
3 ASSESS | Readiness to quit
 ‘How do you feel about your smoking at the moment?’
 ‘Are you ready to quit now?’
Smokescreen for the 1990s. Richmond R, Mendelsohn C et al.1991
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Smoking cessation for alcohol and other drug users
3 ASSESS | Nicotine dependence
 Time To First Cigarette (TTFC) 1,2
– Smoking within 30 minutes of waking
is the single best predictor of nicotine
dependence
– <5 mins indicates high dependence
 Guide to
– Need for medication
– Severity of withdrawal
– Intensity of support
1. Fagerström K. Time to first cigarette; the best single indicator of tobacco dependence? Monaldi Arch Chest
Dis 2003 2. Heatherton T. Measuring the heaviness of smoking. British Journal of Addiction 1989
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Smoking cessation for alcohol and other drug users
4 ASSIST | Develop coping strategies
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Smoking cessation for alcohol and other drug users
4 ASSIST | Barriers to quitting
Nicotine withdrawal
Fear of
failure
Weight gain
Social pressure
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Stress
Smoking cessation for alcohol and other drug users
4 ASSIST | Medication
 “… for all motivated smokers who have evidence of nicotine
dependence” (smoke <30 mins of waking)
 First line treatments
– Nicotine replacement therapy: first choice in hospital due to
quick response
– Varenicline
– Bupropion
 All work by relieving cravings and withdrawal symptoms
Zwar N. Supporting smoking cessation. A guide for health professionals. RACGP 2014
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Smoking cessation for alcohol and other drug users
Effectiveness
Intervention
Increase in
quit rate
Nicotine replacement therapy monotherapy
(patch, gum, inhalator, lozenge, mouth spray)
Bupropion
84%
82%
Varenicline
Combination NRT (patch + quick acting form)
288%
Cahill K. Pharmacological interventions for smoking cessation. An overview and network meta-analysis.
Cochrane review 2013
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Achievingfor
a smoke
Smoking cessation
alcoholfree
andhospital
other drug users
NRT product categories
Speed of
action
Time to peak
blood levels
Use
Nicabate 3-7 h
Nicotinell 9-12 h
Continuous application
Nicorette 6-9 h
16 hour application
Medium
30-60 minutes
Regular or prn use
Fast
10 minutes
Rescue cravings
Cue-induced cravings
Slow
NRT product
1. Hansson A. BMJ Open 2012 2. Kraiczi H. Nic Tob Res 2011 3. Hukkanen J. Pharmacol Rev 2005
4. Du D. JOSC 2014
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Combination NRT
Nicotine
patch
Steady
background
nicotine levels
Slow acting
Oral nicotine
products
For cue-induced or
breakthrough
cravings
Intermediate
or fast acting
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Smoking cessation for alcohol and other drug users
Varenicline
 The most effective monotherapy 1
 3-month course of twice daily
tablets
 Optional second 3-month course
 Nausea. Increase dose slowly and
take with food
 PBS authority
1. Cahill K. Pharmacological interventions for smoking cessation: an overview and network metaanalysis. Cochrane Review 2013
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Smoking cessation for alcohol and other drug users
Neuropsychiatric side-effects
 Post-marketing case reports of depressed mood, agitation,
changes in behaviour, suicide ideation and suicide
– The least valid research design
– Can’t determine causality
– Poor report quality
 Subsequent studies and analyses with more robust design
have found no evidence of a causal relationship 1
–
–
–
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RCTs: Smokers without mental illness (10 trials)
RCTs: Schizophrenia, depression
Pooled RCTs, meta-analyses
Large observational studies
1. Cahill K. Cochrane Database 2012
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Smoking cessation for alcohol and other drug users
Recommendations
 Varenicline can be used in patients with mental illness and
SUDs
 Advice to patients
– There have reports of changes in mood and behaviour but
there is no evidence that varenicline is the cause
– Advise family and carers to report any unexplained changes
– Stop at first sign of these symptoms and contact the doctor
Zwar N. Supporting smoking cessation. A guide for health professionals. RACGP 2014
37
Smoking cessation for alcohol and other drug users
Bupropion
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As effective as NRT monotherapy
Many potential drug interactions
1:1,000 seizure risk
Contraindicated in
– Increased seizure risk:
Seizures: CNS tumours;
excessive alcohol or benzodiazepine
use; bulimia, anorexia nervosa;
history of head trauma
– Pregnancy
Hughes JR. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2014
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Smoking cessation for alcohol and other drug users
5 ARRANGE | Follow up
 Ongoing advice, support and encouragement
 Review problems
 Medication monitoring
 Increases success rates
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Smoking cessation for alcohol and other drug users
Specific management issues
for smokers with
substance use disorders
Some general principles
 Smoking cessation should be integrated into the routine
care of other drug addictions
 Concurrent treatment preferred 1
 Use standard behavioural and pharmacological treatments
 Smokers with SUDS may require
– More intensive, longer-term treatment 2,3
– Higher dose and combination pharmacotherapy
4
1. Prochaska JJ. J Clin Psychol 2004 2. Richter K. Subst Abuse Treat Prev Policy 2006 3. Okoli C. J
Dual Diagn 2014 4. Schroeder SA. Annu Rev Pub Hlth 2010
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Smoking cessation for alcohol and other drug users
Address perceived barriers
Barriers to quitting smoking reported by AOD users:
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Quitting will compromise treatment of alcohol /other drugs
Loss of a tool for coping with stress, low mood
Withdrawal symptoms: irritable, anxious, restless
Intolerable urges to smoke
Urges to drink or use drugs will be overwhelming
Gaining weight
1. Asher M. J Subs Abuse Treat 2003 2. Bloom EL. SRNT 2014
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Smoking cessation for alcohol and other drug users
Methadone
 Extremely low quit rates:
4-5% at 6m 1,2
 No sustained benefits from
NRT 1-4 or varenicline 5,6
 Consider tobacco harm reduction,
eg nicotine patch or e-cigarettes long-term
1. Stein 2006 2. Shoptaw 2002 3. Reid 2008 4. Stein 2013 5. Navhi 2014 6. Stein 2013
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Smoking cessation for alcohol and other drug users
Alcohol
 Varenicline may be the
drug of choice for heavy
drinking smokers
 Effect on alcohol use
– Reduces alcohol cravings 1
– Reduces alcohol consumption 1
– Effectiveness comparable to naltrexone and acamprosate
2
 Combination NRT more effective than monotherapy in heavy
drinkers 3
1. Erwin B. Ann Pharmacother 2014 2. Litten RZ. J Addict Med 2013 3. Cooney NL. Addiction 2009
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Smoking cessation for alcohol and other drug users
Cannabis
 2 out of 3 users ‘mull’
- NRT may be required
 Simultaneous treatment
recommended 1,2,3
– Continuing either drug increases risk of relapse of the other
– Reinforcement from similar management strategies
• Motivational interviewing, quit day, coping strategies for triggers,
relaxation strategies, managing withdrawals - urge surfing, exercise
 More severe withdrawal from both drugs
1. Agrawal A. Addiction 2012 2. Peters E. Addiction 2012 3. Management of cannabis use disorder.
A clinicians guide. NCPIC
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Smoking cessation for alcohol and other drug users
Take home messages
1. Substance users are more likely to die from smoking than from
their drug of choice
2. Substance users want to quit smoking and can quit, but may have
lower quit rates
3. Smoking does not relieve stress, but actually increases it
4. Quitting smoking does not compromise recovery from other drugs
5. Concurrent treatment is recommended where possible
6. Substance users may need more intensive support and
pharmacotherapy
7. Ask all patients if they smoke and offer help to quit using the
AAR or 5As frameworks
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