Nicotine

On a scale from 0 to 10 how important is it to treat tobacco use in a patient with a substance use disorder? And why?

Smokers have a 30% – 40% higher risk of diabetes than non-smokers. U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Tobacco is the #1 preventable cause of death in the USA. Tobacco causes more deaths per year than the following causes combined: alcohol, AIDS, homicide, suicides, car crashes, illegal drugs. From Vision 2020, NC Tobacco Prevention & Control Branch, 2016

Secondhand smoke and the harmful chemicals in it are known causes of Sudden Infant Death Syndrome, respiratory infections, ear infections, and asthma attacks in infants and children. They are also known causes of heart disease, stroke, and lung cancer in adult non-smokers. https://www.cdc.gov/vitalsigns/tobacco/infographic.html CDC Vital Signs infographic

Just 5 minutes of secondhand smoke can hurt you; increasing risk for asthma and heart attacks. This might explain why when the smoke free restaurants and bars law went into effect in NC, in the week following emergency room visits for cardiac events dropped 21%. And why State Operated Mental Health Facilities saw a decrease in sick days among staff after going tobacco free. CDC vital signs infographic.

The U.S. Surgeon General states there is no safe level of secondhand smoke. Centers for Disease Control and Prevention (US), U.S. Department of Health and Human Services. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Publications and Reports of the Surgeon General. 727. ncbi.nlm.nih.gov/books/NBK44324/

Nicotine bioavailability is route-dependent with the highest approximately 90% when inhaled (e.g. cigarettes) and approximately 60% when used orally (e.g. chew). Fagerstrom, K. (2014). Nicotine: Pharmacology, Toxicity and Therapeutic use. Journal of Smoking Cessation. 9(2), 53–59. doi:10.1017/jsc.2014.27

After a puff, high levels of nicotine reach the brain in 10–20 seconds, faster than with intravenous administration, producing rapid behavioral reinforcement. Benowitz, N. L., Hukkanen, J., & Jacob, P., 3rd (2009). Nicotine chemistry, metabolism, kinetics and biomarkers. Handbook of Experimental Pharmacology. (192), 29–60. doi.org/10.1007/978-3-540-69248-5_2

The rapidity of rise in nicotine levels permits the smoker to titrate the level of nicotine and related effects during smoking, and makes smoking the most reinforcing and dependence-producing form of nicotine administration. Benowitz, N. L., Hukkanen, J., & Jacob, P., 3rd (2009). Nicotine chemistry, metabolism, kinetics and biomarkers. Handbook of Experimental Pharmacology. (192), 29–60. doi.org/10.1007/978-3-540-69248-5_2

Researchers have largely overlooked other aspects of the smoking habit that may also be important: the habit and conditioning associated with smoking; the role of the object – that is, the cigarette itself; and the psychosocial aspects of smoking. Fagerstrom, K. (2014). Nicotine: Pharmacology, Toxicity and Therapeutic use. Journal of Smoking Cessation. 9(2), 53–59. doi:10.1017/jsc.2014.27

Aren’t cigars safer? Compared to cigarettes, cigars:

Have more tobacco & nicotine, and longer smoking time (enough to cause or sustain addiction)
Contain higher levels of cancer-causing agents, more tar and higher concentrations of toxins (carbon monoxide, hydrocarbons, heavy metals)
Risks exist whether inhaled or not
Associated with cancers of the oral cavity, larynx, esophagus, and lung; increased coronary heart disease and lung disease National Cancer Institute (2010). Cigar smoking

E-cigarettes/vape pens allow the user to make large clouds that many think are just water vapor

In reality the “cloud” is a mixture of many different chemicals that were either present in the e-liquid before, or produced during, the heating process
A vapor is a chemical that has evaporated
An aerosol is a mixture of liquid particles suspended in a gas and can contain many chemicals
Instead of just mixing with the air like a pure gas, aerosols can leave drops behind NC Tobacco Control

What’s in the aerosol?

Nicotine
Fine and ultrafine particles delivered are similar to conventional cigarettes
Some tobacco-specific carcinogens and toxins have been documented
Propylene glycol – can cause respiratory distress and illness (Grana et al., 2014)
Propylene oxide – a potential carcinogen and breathing irritant (Sleiman et al., 2016)
Heavy Metals: tin, silver, iron, nickel aluminum, sodium, chromium, copper, magnesium, manganese, lead, potassium, and silicate nanoparticles NC Tobacco Control

Worldwide, tobacco use causes nearly 6 million deaths per year. Tobacco use will cause >8 million deaths annually by 2030. World Health Organization (2011)

80% to 95% of alcoholics smoke cigarettes. 3 times higher than among the population as a whole. Patten, CA et al. (1996). Can psychiatric and chemical dependency treatment units be smoke free? Journal of Substance Abuse Treatment. 13(2):107-118.

70% of alcoholics are heavy smokers (>1 PPD) compared with 10% of the general population. National Institute on Alcohol Abuse and Alcoholism (1998)

Smokeless tobacco is a cause of cancer: oral, pharynx, esophagus, and pancreas. American Cancer Society (2015).

Smokeless tobacco use is associated with an increased risk of acute myocardial infarction. Teo KK et al. (2006). Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 368:647–658

Nicotine poses unique dangers to the developing human.

Nicotine is toxic to developing fetuses and impairs fetal brain and lung development
Poisonings occur among users via ingestion of nicotine liquid, absorption through skin, and inhalation
Nicotine use while adolescent brain is developing can disrupt brain circuit formation England, L. J. et al. (2015). Nicotine and the developing human: A neglected element in the electronic cigarette debate. Am Journ Prev Med

Every year 520,000 Americans die from tobacco-related illness, about half of them are people with behavioral health disorders. Prochaska JJ, Das S, Young-Wolff KC. (2017). Smoking, Mental Illness, and Public Health. Annual Review of Public Health. 38:165–85. pubmed.ncbi.nlm.nih.gov/27992725/

In 2020, nearly 13 of every 100 U.S. adults aged 18 years or older (12.5%) currently smoked cigarettes. CDC Current Cigarette Smoking Among Adults in the United States. cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

Severity of nicotine dependence is associated with higher craving in alcohol-dependent patients. Suggests shared pathophysiological mechanisms in alcohol craving and nicotine dependence. Hillemacher, T. et al. (2006). Nicotine dependence is associated with compulsive alcohol cravings. Addiction. 101(6): 892-7.

Studies have observed 5%-15% of people in substance use treatment starting to smoke in treatment. Kohn CS, Tsoh JY, Weisner CM. (2003). Changes in smoking status among substance abusers: Baseline characteristics and abstinence from alcohol and drugs at 12-month follow-up. Drug and Alcohol Dependence. 69(1):61–71. pubmed.ncbi.nlm.nih.gov/12536067/ Friend KB, Pagano ME. (2004). Smoking initiation among nonsmokers during and following treatment for alcohol use disorders. Journal of Substance Abuse Treatment. 26(3):219–24. pmc/articles/PMC3272765 Weinberger AH, Platt J, Esan H, Galea S, Erlich D, Goodwin RD. (2017). Cigarette smoking is associated with increased risk of substance use disorder relapse: A nationally representative, prospective longitudinal investigation. Journal of Clinical Psychiatry. 78(2):e152–60. pmc/articles/PMC5800400/

In the US, people with a behavioral health condition who use tobacco lose 25 years of life, on average. Prochaska JJ, Das S, Young-Wolff KC. (2017). Smoking, Mental Illness, and Public Health. Annual Review of Public Health. 38:165–85. pubmed.ncbi.nlm.nih.gov/27992725/

One large, long-term study found that over half of people who went to substance use treatment died from an illness caused by tobacco use. Bandiera FC, Anteneh B, Le T, Delucchi K, Guydish J. (2015). Tobacco-related mortality among persons with mental health and substance abuse problems. PLoS ONE. journals.plos.org/plosone/article?id=10.1371/journal.pone.0120581

Quitting smoking lowers overall stress after about 1-3 weeks with effects similar to an anti-depressant. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. (2014). Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ (Online): 348. bmj.com/content/348/bmj.g1151

For someone who wants to quit using other substances, getting treatment for tobacco use at the same time makes them 25% more likely to avoid substance use in the future. Prochaska JJ, Delucchi K, Hall SM. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology. 72(6): 1144–56. pubmed.ncbi.nlm.nih.gov/15612860/

The cycle of withdrawal happens throughout the day between the times you smoke, vape, or use tobacco. Exiting the stressful cycle of nicotine highs and lows, along with having more energy because you can breathe better, may explain why quitting is good for long-term mental health. Taylor G, McNeill Girling A, Farley A, Lindson-Hawley N, Aveyard P. (2014). Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ. (Online). bmj.com/content/348/bmj.g1151

For people with a substance use disorder, using tobacco often happens along with drinking alcohol or using other drugs. One can be a trigger for the other. Prochaska JJ, Delucchi K, Hall SM. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology. 72(6):1144–56. pubmed.ncbi.nlm.nih.gov/15612860/

Continuing or starting to smoke increases the risk of returning to substance use after treatment. Weinberger, Platt, Esan, Galea, Erlich, and Goodwin (2017). J Clin Psychiatry. doi: 10.4088/JCP.15m10062. ncbi.nlm.nih.gov/pubmed/28234432 drugabuse.gov/news-events/nida-notes/2014/10/smoking-cessation-does-not-interfere-recovery-substance-use

Some studies have found that secondhand smoke increases the risk for triggering a seizure in people with epilepsy Rong L, Frontera AT, Benbadis SR. (2014). Tobacco smoking, epilepsy, and seizures. Epilepsy and Behavior. Vol 31: p. 210–8. pubmed.ncbi.nlm.nih.gov/24441294/

Secondhand aerosol is the cloud of chemicals that comes from e-cigarettes or vapes. U.S. Department of Health and Human Services. (2016). E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA.

One more risk from smoking, vaping, or dipping: kids who see adults they look up to using tobacco are more likely to use tobacco in the future Centers for Disease Control and Prevention. Smokefree Policies Reduce Smoking. (2020). cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/reduce_smoking/index.htm Vuolo M, Staff J. (2013). Parent and child cigarette use: A longitudinal, multigenerational study. Pediatrics. 18;132 (3); e568. pmc/articles/PMC3876755/

Offering a 100% tobacco-free environment with tobacco-use treatment is the first step towards health equity for people with behavioral health conditions. Not only that, but it is an important part of treatment because becoming tobacco free is associated with improved mental health and substance use recovery outcomes Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annual Review of Public Health. (2017). 38:165–85. pubmed.ncbi.nlm.nih.gov/27992725/

People with behavioral health conditions who use tobacco are just as interested in quitting as people without. Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. (2017). Annual Review of Public Health. 38:165–85. Available from: pubmed.ncbi.nlm.nih.gov/27992725/

Most people want to quit. U.S. Department of Health and Human Services. (2020). Smoking Cessation: A Report of the Surgeon General. Atlanta, GA.

Most people who use tobacco try to quit each year, yet without a tobacco-free environment and treatment, few are successful U.S. Department of Health and Human Services. (2020). Smoking Cessation: A Report of the Surgeon General. Atlanta, GA.

Research shows that smoking cessation does not disrupt alcohol abstinence and actually enhances the likelihood of longer-term sobriety. Gulliver SB et al. (2006). Smoking cessation and alcohol abstinence: What do the data tell us? Alcohol Research & Health: the Journal of the National Institute on Alcohol Abuse & Alcoholism. 29(3):208-12.

Tobacco use is correlated with relapse. Addressing tobacco in treatment improves outcomes. Stuyt EB. (2014). Enforced Abstinence from Tobacco During In-Patient Dual-Diagnosis Treatment Improves Substance Abuse Treatment Outcomes in Smokers. The American Journal on Addictions.

Inclusion of smoking cessation treatment into addiction programs does not negatively affect rates of treatment completion or motivation for abstinence. Sharp JR et al. (2003). Targeting nicotine addiction in a substance abuse program. Science Practice and Perspectives. 2:33–40.

Becoming tobacco free is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. Hirshbein (2011); Prochaska, Hall, & Bero (2008) drugabuse.gov/news-events/nida-notes/2014/10/smoking-cessation-does-not-interfere-recovery-substance-use

Though it feels like a relief for a short time, the body actually goes through withdrawal – physically and mentally – between cigarettes, because it’s addicted. U.S. Department of Health and Human Services. (2020). Smoking Cessation: A Report of the Surgeon General. Atlanta, GA.

In the meantime, it’s important to get quit coaching and medication that will lessen your stress and make it 2x more likely that you will be able to quit for good. U.S. Department of Health and Human Services. (2020). Smoking Cessation: A Report of the Surgeon General. Atlanta, GA.

Prior to going tobacco-free, some organizations go through various earlier attempts and stages of change at the level of the entire organization.

Some individuals: