Today there's a new answer to Bill's question: After sobriety based on freedom from alcohol comes the issue of tobacco addiction. Hazelden meets this issue head-on with concurrent treatment programs--those that tackle nicotine, alcohol, and other drugs at the same time--and tobacco recovery programs offered later in one's continuing care journey.

Of course, quitting tobacco is not a requirement for quitting alcohol or other drugs. People can achieve a satisfying sobriety even if they continue smoking. At the same time, many alcoholics do try to quit tobacco, and many of them succeed.

Research links tobacco, alcohol addiction
Today the single greatest cause of disease and premature death in America is tobacco use. Each year, diseases related to tobacco kill 430,000 Americans. Nearly one-quarter of American adults are smokers. Three thousand children and adolescents become regular tobacco users every day. The U.S. Public Health Service pegs the annual cost of tobacco-related death and disease at $100 billion.1

Hard drinkers are stereotyped as heavy smokers, and research supports that view. Studies indicate that:

• Between 80 and 95 percent of alcoholics smoke cigarettes, a rate that is more than three times that for the general American population.2
• Nearly 70 percent of alcoholics are heavy smokers (ie, smoke more than one pack of cigarettes per day).3
• Heavier drinkers puff their cigarettes more and draw in more smoke with each puff.4

Unfortunately, heavy smoking and heavy drinking create a life-threatening synergy: Using both drugs over the long term increases health risks more than using either drug alone. When compared to people who neither smoke nor drink, smokers are seven times more likely to develop mouth and throat cancer; drinkers are six times more likely; and those who smoke and drink are 38 times more likely.5

This is the reason that Richard D. Hurt, MD, head of the Nicotine Dependence Center at Mayo Clinic in Rochester, Minn., advocates concurrent treatment for tobacco and alcohol addiction. Hurt's own research provides supporting data.6 "For patients who have been through addictions treatment, half of their deaths will come from tobacco, while one-third will come from alcohol-related causes," Hurt says.

Quitting tobacco can enhance recovery
Yet there's a bright spot to be found in the pages of these published studies: Alcoholic smokers have the same desire to quit tobacco as other smokers. Of the 48 million adult smokers in America, about 70 percent want to quit tobacco. That figure holds for alcoholic smokers as well.7

This is true even though alcoholics in treatment have traditionally not been encouraged to quit smoking. Professionals and patients alike feared that nicotine withdrawal would trigger a relapse to drinking. Research does not support this view.8 Even without formal treatment, people who quit drinking often stop smoking at the same time.9

The benefits of dual recovery are also synergistic. After one year of abstinence from cigarettes, former smokers cut their excess risk of heart disease by almost one half. For recovering alcoholics, the benefit of quitting tobacco may be even greater.10

David Jones, nicotine addiction specialist, believes that quitting nicotine in all its forms enhances the quality of treatment for other addictions. The reason: Freedom from nicotine forces people to face tough emotions.

"Even though nicotine is a stimulant, it has an effect on brain chemistry that suppresses emotions," Jones explains. "So, a smoker goes into a therapy group and the counselor asks, 'How do you feel?' The smoker says he feels fine. And he does feel fine--nicotine has altered his mood. He turns whatever feelings that did come up back inward to himself, and this keeps him from getting the full benefit of treatment."

People who quit tobacco might feel more discomfort when unpleasant feelings first arise. But those undiluted feelings can deepen and intensify the treatment experience. When nicotine is no longer available to put a lid on emotion, drinkers may be more ready to admit their powerlessness and accept help.

Options for quitting increase
According to the federal government's latest guidelines for health professionals, current treatments for tobacco dependence offer the "greatest single opportunity to staunch the loss of life, health, and happiness caused by this chronic condition."11

The bottom line is that smokers who want to quit have more options than ever before. The federal guidelines list four kinds of nicotine replacement therapies: nicotine gum, the nicotine inhaler, nicotine nasal spray, and the nicotine patch. These treatments aim to reduce withdrawal symptoms, allowing people to consume nicotine in highly controlled and steadily decreasing doses. In addition, replacement therapy provides nicotine without the toxins found in cigarette smoke.

The guidelines also recommend three non-nicotine medications to reduce withdrawal symptoms: the antidepressant bupropion (Zyban), the most commonly prescribed non-nicotine medication to deal with tobacco dependence, and clonidine and nortriptyline, two second-line medications that require more medical supervision. And, the guidelines endorse counseling for everyone who tries to quit smoking. Counseling can help people create a realistic plan for quitting and learn effective ways to deal with tobacco cravings.

Hazelden offers flexible program
People who enter treatment at Hazelden's campus in Center City, Minn., have an array of options for quitting tobacco. All options are voluntary and are based on a smoker's personal readiness to quit.

"We really start dealing with the issue of nicotine before patients even come into treatment," says Tim Sheehan, PhD, vice president of Academic Affairs at Hazelden and former vice president of Minnesota Recovery Services. "We collect enough information before admission so that we know if a person really has a nicotine dependency. For them we provide an orientation group--an informational session that gets people thinking about the process of addiction and what they can expect if they're going to stop smoking."

Some people who complete this orientation group are ready to stop. In that case, a unit counselor creates an appropriate treatment plan. This plan might include a pattern of nicotine withdrawal recommended by the medical services unit at Hazelden. Other people prefer to quit "cold turkey," and that request will also be considered.

Rounding out the smoking cessation program is individual counseling along with group support. The support group becomes a forum for applying the wisdom of the Twelve Steps to tobacco dependency. "It helps people understand their powerlessness over nicotine," says Sheehan. "The group also helps them understand that there is hope, and that people do indeed recover."

Some smokers go through the initial orientation group and conclude that they're not ready to quit tobacco just yet. Hazelden honors that choice. At the same time, a smoker's continuing care plan might include a program such as Your Next Step, Hazelden's seven-day residential nicotine recovery program.

When it comes to nicotine replacement therapy, Hazelden also considers individual need. "Our long-term strategy is to use the knowledge that's gained from the Twelve Steps to help people be totally abstinent from all nicotine products," Sheehan explains. "But we certainly will use nicotine replacement temporarily to manage withdrawal."

Tobacco recovery programs at the Hazelden Center for Youth and Families (HCYF) in Plymouth, Minn., and Fellowship Club in St. Paul follow a similar design. "Both places offer a basic nicotine orientation group for anyone who is using tobacco," says Barry McMillen, supervisor of Nicotine Dependency Treatment Services. "That's virtually everybody at HCYF and a good portion of the people at Fellowship Club. People who then think it's a good idea to do something about their addiction can come to a weekly tobacco recovery group." Again, both groups are voluntary.

Adolescents in treatment at HCYF are especially volatile when it comes to tobacco use. "They can get on a jag, then quit smoking for a month or two, and then all of a sudden turn around and start smoking again," says McMillen. "Now they're addicted and they're in a treatment situation where their primary drug of choice has been taken away. They don't always want to hear about tobacco recovery, but we offer information to them and trust that it will make an impact later on."

In Alcoholics Anonymous, Bill W. described alcohol as "cunning, baffling, and powerful." It's a tribute to him that nicotine is currently seen in the same light and that treatment programs based on the Twelve Steps are now lighting a path to freedom from tobacco.

To find out more about Hazelden resources, call (800) 328-9000 or visit the Hazelden online bookstore.

David C. Jones is author of Yes! You Can Stop Smoking: Even If You Don't Want To (Dolphin Press, 1996, [800] 547-7867) and a workbook with the same name.

Other quit information and opportunities are offered by:

• American Heart Association, (800) 242-8721, www.americanheart.org
• American Cancer Society, (800) 320-3333, www.cancer.org
• American Lung Association, (800) 586-4872, www.lungusa.org
• National Cancer Institute, (800) 422-6237, www.nci.nih.gov
• Nicotine Anonymous, (415) 750-0328, www.nicotine-anonymous.org

References

1. Fiore, MC, et al. Treating tobacco use and dependence. Quick Reference guide for clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.
2. Patten, CA, et al. Can psychiatric and chemical dependency treatment units be smoke free? J Subst Abuse Treat 13(2):107-118, 1996.
3. Collins, AC, Marks, MJ. Animal models of alcohol-nicotine interactions. In: Fertig, J.B., and Allen, J.P. Alcohol and Tobacco: From Basic Science to Clinical Practice. NIAAA Research Monograph No. 30. NIH Pub. No. 95-3931. Washington, DC: Supt. of Docs, U.S. Govt. Print. Off., 1995. pp. 129-144.
4. Keenan, RM, et al. The relationship between chronic ethanol exposure and cigarette smoking in the laboratory and the natural environment. Psychopharmacology 100:73-83, 1990.
5. Blot, WJ. Alcohol and cancer. Cancer Res (supp.) 52:2119s-2123s, 1992.
6. Hurt, RD. Mortality following inpatient addictions treatment. JAMA 275(14):1097-1103, 1996.
7. Centers for Disease Control, Office on Smoking and Health. Fact sheet: smoking cessation among recovering alcoholics. URL: http://www.cdc.gov/od/oc/media/fact/smokcara.htm, Dec. 5, 1997.
8. Shiffman, S, Balabanis, M. Do drinking and smoking go together? Alcohol Health Res World 20(2):107-110, 1996.
9. Hurt, RD, et al. Nicotine dependence treatment during inpatient treatment for other addictions: A prospective intervention trial. Alcohol Clin Exp Res 18(4):867-872, 1994.
10. Centers for Disease Control, Office on Smoking and Health. Fact sheet: smoking cessation among recovering alcoholics. URL: http://www.cdc.gov/od/oc/media/fact/smokcara.htm, December 5, 1997.
11. Fiore, MC, et al. Treating tobacco use and dependence. Quick reference guide for clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.

Published in The Voice, Summer 2002