R ESPONSE: GETTING TOUGH WITH SMOKING

Steven Shoptaw: We don’t know why, but the use of nicotine is associated with the use of other substances, whether you look retrospectively in a clinical trial situation or prospectively in carefully defined groups. The association is always there and always very clear. My data show that among methadone-maintained patients who were trying to quit smoking, they were more likely to use illicit drugs on any day they smoked. Anne Joseph: There is no doubt that quitting smoking has health benefits with respect to lung disease and many other conditions. Whether it has good, bad, or no effects on chemical dependency outcomes is still up in the air, unfortunately. For a long time there were worries, not founded on any data, that there would be adverse effects. There have been about a dozen studies that did not seem to demonstrate such effects, and a few suggested smoking cessation might even have a beneficial effect on treatment outcomes. Lirio Covey: Most of the evidence has been on recovered groups, and it shows that if people quit smoking after being abstinent from alcohol for a while, quitting smoking does not jeopardize that abstinence. Dr. Sharp and colleagues, however, are talking about people in early recovery. We know very little about how smoking cessation will affect that group. I have some concerns. I see a parallel to the state of our knowledge with regard to smoking and psychiatric conditions such as major depression. We know a lot about people with past major depression. But we don’t know what will happen if people stop smoking when they are still depressed or just recently got over their depression. Joseph: We just completed a randomized trial of treatment for nicotine dependence given concurrently with alcohol treatment, comparing it to nicotine treatment delayed by 6 months. The smoking cessation outcomes were identical in the two groups, in the neighborhood of 15 or 16 percent at 12 months. However, there is sometimes a trend and sometimes a statistically significant difference in alcohol treatment outcomes that favors delayed treatment. This is not the result we were expecting. Covey: Anne, can you speculate on the explanation for your finding? Joseph: One possibility has to do with pharmacological interactions between nicotine craving and alcohol craving. For example, abstinence from cigarettes may cause nicotine craving, and that might trigger intense craving for alcohol. Depression is another possible explanation for these findings. Many alcohol-dependent patients are depressed. If their depression is exacerbated by nicotine abstinence or relative nicotine deprivation, perhaps patients will use alcohol to self-treat their depression. Shoptaw: When you work with people who have multiple substances of dependence, removing one doesn’t necessarily affect the others. Or it may. We don’t know. Joseph: Our study results have yet to be duplicated. In addition, in contrast to the ATC scenario described in this article, the nicotine treatment in our study was not compulsory. All in all, the question of how concurrently treating nicotine dependency will affect other dependency outcomes is still up in the air. Covey: I think the authors are to be commended for taking this approach, even though a lot of their actions and policies are based on very slim evidence. I can see it as a potential test. Joseph: My guess is that when it all settles out, there will probably be some situations where it’s not right to treat nicotine dependency, but in the majority of situations, it’s probably right. Right now we under-treat nicotine dependency in the majority of drug and alcohol treatment populations. It is important to experiment with new approaches, such as those Sharp describes.