Smoking

Smoking

By Dr.Fourkan Ali

Individuals with substance use disorders smoke at rates nearly three times the general population [1]. Over 75% of those in early recovery from substance use disorders are heavy smokers [2]. Not only is tobacco use a predictor of tobacco related disease and death [3], but also a risk factor for substance disorder relapse [4,5]. The converse is also true; cessation of nicotine use appears to be protective of substance use relapse [6-8]. These facts emphasize the importance of addressing tobacco use while patients are in treatment for substance use disorders.

There is still some debate about the optimal timing of smoking cessation treatment and substance use disorder treatment, with conflicting hypotheses regarding the advisability of concurrent treatment versus consecutive treatment. Some researchers report that attitudes of treatment staff, lack of knowledge, relatively low priority compared to other substance use disorder treatment and lack of availability of smoking cessation treatment modalities are barriers to concurrent treatment as well as concern over substance relapse [9,10]. While some of these factors may create difficulties in treatment, concurrent treatment in one study produced the highest nicotine abstinence rate [11]. In that study, tobacco cessation treatment was fully integrated with the substance use disorder treatment program. Additionally, several other studies have suggested treatment of nicotine dependence does not lead to an increase in substance use and may even support recovery [6-9,11,12]. Despite this evidence, some patients expect that smoking cessation will inhibit their recovery from other substances and may thus be less receptive to smoking cessation [13].

Other relative barriers to smoking cessation include individuals with a diagnosis of a serious mental illness, who smoke at a rate at least double the general population [1,14]. Ethnic disparities exist in tobacco use cessation rates, with African-Americans the least likely to report successful cessation of tobacco [15]. Women are less likely than men to maintain nicotine cessation in some studies [16]. Although similarly as motivated to quit as their more socio-economically advantaged counterparts, homeless patients smoke at higher rates (70%) [17], and are significantly less likely to quit smoking [18]. Veterans have been shown to have higher rates of smoking compared to the general population with rates of nicotine use further increased in those deployed into combat areas [19-21].

This study examined some of these factors to determine the success of using smoking cessation medications to treat veterans while admitted to a residential rehabilitation treatment program.

Methods

All study procedures were reviewed and approved by the Hampton Veterans Affairs Medical Center Institutional Review Board. As this was a retrospective records review, a waiver of informed consent was obtained. A retrospective review was conducted of 643 medical records from all patients admitted between 2009 and 2011 to a Veterans Administration residential substance use treatment program. At admission all patients were administered a self-report survey documenting amount of and type of nicotine used. Those that met criteria for nicotine dependence (n=527 or 82%) were offered smoking cessation medications during treatment and were administered a counseling session with the psychiatrist of at least 30 minutes duration. The patients that elected to use medication to aid in smoking cessation efforts were offered either nicotine patches (7, 14 or 21 mg/24 hours) nicotine gum (2 or 4 mg) or nicotine lozenges (2 mg) or bupropion alone or in combination. Self-report of smoking reduction or cessation during treatment was tracked. All patients were referred to smoking cessation classes, but attendance was not tracked. Bivariate statistics and binary logistic regression analysis was performed in SPSS, version 18.

Results

Demographics

All patients enrolled in the residential treatment program and this study were veterans. The majority were men (91.8%) and African Americans comprised the majority ethnicity (69.9%) compared to Caucasian (28.5%) or other minorities (1.5%). The mean age was 50 (range 21-67 years, standard deviation 8.7). Most patients were divorced (47%) with smaller percentages of single (21%), married (13%), separated (16%) and widowed (3%). Table 1 shows the sample characteristics with respect to legal status, dental problems, back pain, homelessness and military service era.