Treating Tobacco Dependence in Patients with Other Addictions

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Treating Tobacco Dependence in Patients with
Other Addictions

• Richard D. Hurt, M.D.
• Professor of Medicine, Mayo Clinic College of
  MedicineDirector, Nicotine Dependence
  Centerhttp//ndc.mayo.edu

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Smoking and Mental Illness

• 22 of people who have never been diagnosed with
  a mental illness currently smoke.
• 34.8 of people who have had been diagnosed with
  a mental illness sometime in their life currently
  smoke.
• 41 of people who have been diagnosed with a
  mental illness In the past month currently smoke
• 44 of all cigarettes smoked are by people with a
  past-month mental health diagnosis.

Lasser et. Al. 2000
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Nicotine Dependence and Psychiatric
DisordersU.S. Adults

• National Epidemiologic Survey on Alcohol and
  Related Conditions
• Face-to-face interviews (N43,093) to determine
  co-occurrence of DSM-IV nicotine dependence and
  Axis I II psychiatric disorders
• NIAAA Alcohol Use Disorder and Associated
  Disabilities Interview Schedule DSM-IV
• Current cigarette use any use in past year.
  Characterized on days smoked and cigarettes
  usually smoked

Grant BF. Arch Gen Psychiatry 611107, 2004
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Nicotine Dependence and Psychiatric
DisordersU.S. Adults
Total Males Females
Current smokers 24.9
Nicotine dependence 13 14 11
Alcohol abuse 5 7 3
Alcohol dependence 3 5 2
Grant BF. Arch Gen Psychiatry 611107, 2004
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Prevalence of Psychiatric Disorders Among
Respondents with Nicotine Dependence
Alcohol use disorder 23
Alcohol abuse 9
Alcohol dependence 13
Major depression 17
Anxiety disorder 22
Personality disorder 32
Grant BF. Arch Gen Psychiatry 611107, 2004
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Prevalence of Nicotine Dependence Among
Psychiatric Disorders
Alcohol use disorder 34
Alcohol abuse 25
Alcohol dependence 45
Drug use disorder 52
Drug abuse 45
Drug dependence 69
Major depression 30
Anxiety disorder 25
Personality disorder 27
Grant BF. Arch Gen Psychiatry 611107, 2004
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Alcoholism and SmokingBackground

• Regular smoking usually precedes development of
  alcoholism
• 2-3x ? in prevalence of smoking among substance
  abusers
• 10x ? in prevalence of alcoholism among heavy
  smokers vs. nonsmokers
• Smoking alcoholics constitute 26 of all smokers

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Alcoholism and Tobacco DependenceBill Wilson, AA
Co-founder

• A heavy, sloppy smoker all his life, he
  developed emphysema in the 1960s. It killed him.
  He gave his last speech to the International AA
  Convention in Miami in 1970, lifted to the
  platform in a wheelchair, gasping for breath and
  sucking oxygen from the tank that was always with
  him.

Robertson Inside Alcoholics Anonymous
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Mortality Following Inpatient Addictions
TreatmentStudy Design

• Olmsted County patients admitted for inpatient
  addictions treatment 1972-1983
• Follow-up through 1994 Rochester Epidemiology
  Project
• Vital status and death certificates
• CDC classification of alcohol or tobacco-related
  cause of death

Hurt RD, et al. JAMA 2751097, 1996
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Mortality Following Inpatient Addictions
TreatmentPatient Demographics

• n845 (65 men, 35 women)
• Mean age at admission 41.4 years
• 78 alcohol only, 18 alcohol and other drugs
• 75 current and 8 former smokers
• Length of follow-up/patient 10.5?5.6 years
  (8913 pt/yrs)

Hurt RD, et al. JAMA 2751097, 1996
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Hurt RD, et al. JAMA 2751097, 1996
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Mortality Following Inpatient Addictions
TreatmentTobacco or Alcohol Cause of Death
Percent Observed Expected RR
Alcohol 34 73 18 4.1
Tobacco 51 109 53 2.0
Hurt RD, et al. JAMA 2751097, 1996
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Mortality Following Inpatient Addictions
TreatmentConclusions

• High risk for premature mortality
• Tobacco-related diseases leading cause of death
• Treating tobacco dependence is imperative in this
  high risk group

Hurt RD, et al. JAMA 2751097, 1996
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Treating Alcohol and Tobacco Dependence
SimultaneouslyDesign

• Prospective nonrandomized controlled trial with 1
  year abstinence outcomes
• Inpatient addictions treatment unit
• Control group (n50) usual care
• Intervention group (n51)
• Consultation
• Group sessions (5)
• Education sessions (5)
• Telephone follow-up

Hurt RD, et al. Alcohol Clin Exp Res 18867, 1994
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Treating Alcohol and Tobacco Dependence
SimultaneouslySubstance Use History
Intervention N51 Control N50 P
Alcohol only () 74.5 54.0 0.031
Smoking rate (CPD) 25.0?8.7 21.3?10.7 0.052
Smoking onset (age) 14.6?3.7 16.6?5.6 NS
Year smoked 26.6?12.4 19.9?10.8 0.012
Hurt RD, et al. Alcohol Clin Exp Res 18867, 1994
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Treating Alcohol and Tobacco Dependence
SimultaneouslyAbstinence Outcomes
Intervention N51 Control N50 P
No alcohol/drugs at 1 year 68.6 66 NS
Not smoking at dismissal 21.6 10.0 NS
Not smoking at 1 year 11.8 0 0.027
Hurt RD, et al. Alcohol Clin Exp Res 18867, 1994
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Treating Alcohol and Tobacco Dependence
SimultaneouslyConclusions

• 11.8 tobacco abstinence rate acceptable but can
  be improved
• Study run in less than optimal environment
• Perception that it is hard is real
• No apparent negative effect on abstinence from
  alcohol or other drugs
• Unit became tobacco-free after study

Hurt RD, et al. Alcohol Clin Exp Res 18867, 1994
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Nicotine Patch Therapy in Recovering Alcoholic
SmokersBaseline Characteristics
Recovering Alcoholics (n43) Nonalcoholic (n314) P value
CPD 34.1?9.6 28.0?10.4 lt0.001
FTQ 9.1?3.2 8.1?3.3 0.022
Baseline nicotine (ng/mL) 22.8?10.7 18.9?12.1 0.007
Baseline cotinine (ng/mL) 305.5?126.7 261.28 ?118.8 0.049
Hurt RD, et al. Addiction 901541, 1995
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Nicotine Patch Therapy in Recovering Alcoholic
SmokersConclusions

• More nicotine dependent than nonalcoholics
• Can achieve short-term tobacco abstinence with
  nicotine patch therapy
• May require more intensive intervention
• Dose matching
• Longer treatment
• ? behavioral intervention
• ? relapse prevention

Hurt RD, et al. Addiction 901541, 1995
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Nicotine Patch Therapy in Alcoholic
SmokersDemographics
Nonalcoholic (n281) Recovering (n53) Active (n48) P
Age 45.2?1.3 43.8?10.8 42.8?11.2 NS
female 61 42 37 0.001
Smoking rate (CPD) 26.4?9.1 30.6?12.1 29.8?11.3 0.004
FTQ 6.9?1.8 8.4?1.7 7.8?1.9 lt0.001
Hays JT, et al. Ann Behav Med 21244, 1999
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Nicotine Patch Therapy in Alcoholic
SmokersTobacco Abstinence Rates
Hays JT, et al. Ann Behav Med 21244, 1999
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High Dose Nicotine Patch Therapy in Heavy
SmokersMethods

• Post hoc analysis of 1039 heavy smokers (?30 cpd)
• Screened for current alcohol problem with short
  alcohol dependence data questionnaire
• Smokers with alcohol problems in past year were
  excluded
• Nicotine patch dose placebo, 21 mg, 35 mg, or
  42 mg
• Higher nicotine patch doses were slightly more
  efficacious

Hughes, JR, et al. Drug Alcohol Depend 71269,
2003
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High Dose Nicotine Patch Therapy in Heavy Smokers
Past History Past History
No problems (n879) Alcohol Problems (n160)
Age 44 42
men 47 66
Cigs/day 38 38
CO (ppm) 33 34
FTQ 7.9 8.3
Years smoked 26 26
Hughes, JR, et al. Drug Alcohol Depend 71269,
2003
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High Dose Nicotine Patch Therapy in Heavy
SmokersConclusions

• In heavy smokers with or without past history of
  alcohol problems, no difference in
• time to lapse
• prolonged tobacco abstinence
• Thus, past history of alcohol problems does not
  predict a worse outcome

Hughes, JR, et al. Drug Alcohol Depend 71269,
2003
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Bupropion for Smokers with past History of
Alcoholism or DepressionResults

• Neither PHMDD nor alcoholism associated with
  abstinence at EOT (p0.93) or 1 year (p0.23)
• Dose response effect for bupropion at EOT
  (plt0.001) and 1 year (p0.02)

Hayford KE, et al. Br J Psychiatry 174173, 1999
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Pharmacologic Relapse Prevention for Recovering
Alcoholic Smokers
R01 AA-11219
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Nicotine Patch Dose Based on Serum Cotinine
Baseline Serum Cotinine Initial Nicotine Patch Dose, mg/d
? 200 22
201-300 33
gt 301 44
Hurt RD, et al. J Stud Alcohol 66506-516, 2005.
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Tailored Nicotine Patch Therapy for Recovering
Alcoholic SmokersSerum Cotinine
Week 2 Week 2 Week 2
Patch dose n Baseline n Abstinent subjects n Smoking subjects
22 mg
Cotinine 25 165 18 125 7 178
of baseline 77 113
33 mg
Cotinine 49 257 31 233 18 291
of baseline 92 112
44 mg
Cotinine 63 403 36 366 27 405
of baseline 93 101
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Tailored Nicotine Patch Therapy for Recovering
Alcoholic SmokersSmoking Abstinence Rates
100/195
96/195
94/195
94/195
95/195
93/195
94/195
75/195
Hurt RD, et al. J Stud Alcohol 66506-516, 2005.
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Tailored Nicotine Patch Therapy forRecovering
Alcoholic SmokersSmoking Abstinence
Hurt RD, et al. J Stud on Alcohol, 66506, 2005
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Tailored Nicotine Patch Therapy for Recovering
Alcoholic SmokersConclusions

• Excellent 8 week smoking abstinence rate (51)
  with tailored nicotine patch therapy
• Dosing algorithm works
• No evidence of nicotine toxicity
• Very low rate of relapse to drinking

Hurt RD, et al. J Stud Alcohol 66506-516, 2005.
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Nicotine Patch Therapy in Alcoholics

• Efficacy of 21 or 42 mg x 4 wk (then taper)
  nicotine patch doses in heavy smokers (N130)
  with PH alcoholism
• FTND score 7.7, mean smoking rate 31.5 cpd
• Median alcohol abstinence 4 months (69 receiving
  alcoholism treatment at the time of enrollment)
• Longer alcohol abstinence predicted better
  smoking abstinence outcome

Kalman D, et al. Psychol Addict Behav 1878-82,
2004
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Nicotine Patch Therapy in Alcoholics
Smoking Abstinence Rates Smoking Abstinence Rates Smoking Abstinence Rates
Initial Nicotine Patch Dose Wk 1 Wk 4 Wk 12
21 mg/d 35.4 30.7 20.0
42 mg/d 30.8 20.0 9.2
Kalman D, et al. Psychol Addict Behav 1878-82,
2004
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Treating Alcohol and Tobacco DependenceRationale
to Initiate Treatment During Treatment of other
Dependencies

• Serious cause of morbidity/mortality
• Closely related behaviors
• Eliminates a cue to drink
• Common message
• Apply same treatment philosophy
• Protected milieu to initiate an attempt
• Many patients in CD programs express interest in
  stopping tobacco (46-70)

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Treating Tobacco Dependence in Alcoholics in
Treatment or Recovery

• Meta-analysis of 19 randomized controlled trials
• Post-treatment intervention effects (but not
  long-term) were significant and comparable for
  patients in addictions treatment or recovery
• Tobacco dependence interventions provided during
  addictions treatment ? (25) long-term alcohol
  and/or drug abstinence

Prochaska JJ, et al. J Consult Clin Psychol
721144-1156, 2004
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Timing of Alcohol and Smoking Cessation (TASC)

• Smokers in treatment for alcohol dependence
  willing to consider stopping smoking
• Randomized to concurrent treatment or delayed
  treatment 6 months after alcohol dependence
  treatment
• N499, mean age 39.2, mean CPD 25.5, FTND 6.0,
  47 previously used NRT or bupropion

Joseph AM. J Addict Dis 2287-107, 2003
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Timing of Alcohol and Smoking Cessation
(TASC)Smoking Abstinence
ITT ITT
Concurrent (N251) Delayed (N248) P
7 day PP smoking abstinence
3 months 15.5 4.4 lt0.0001
6 months 10.8 5.2 0.2
12 months 12.8 10.1 NS
18 months 12.4 13.7 NS
Joseph AM. J Stud Alcohol 65681, 2004
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Timing of Alcohol and Smoking Cessation
(TASC)Alcohol Abstinence
ITT ITT
Concurrent (N251) Delayed (N248) P
30 day alcohol abstinence
6 months 51 64 0.004
12 months 46 53 0.11
18 months 48 60 0.01
6 month alcohol abstinence
6 months 41 56 0.001
12 months 33 42 0.06
18 months 41 48 0.14
Joseph AM. J Stud Alcohol 65681, 2004
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Does Smoking Abstinence Threaten Sobriety?

• 10 of recovering alcoholics state it does
• 16 report increased craving
• 18 relapse to alcohol/drug use during tobacco
  abstinence

• 90 state it DOES NOT threaten sobriety
• 84 report NO increase in craving
• 82 DO NOT relapse to alcohol/drug use during
  tobacco abstinence

Adapted from John Hughes, 2004
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Concurrent vs Delayed Treatment for Smoking

• Joseph
• N499
• Delayed less likely to enter smoking tx
• No difference in smoking outcomes
• Concurrent had worse alcohol outcomes (p lt.01)

• Kalman
• N36
• Delayed less likely to enter smoking tx
• No difference in smoking outcomes
• Delayed had worse alcohol outcomes (p.07)

Kalman D. J Subst Abuse Treat. 200120233 Joseph
AM. J Stud Alcohol. 200465681
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Unanswered Questions

• Adequacy of brief treatments?
• Concurrent vs. delayed treatment?
• Integrating 12 step and behavioral therapies?
• Interventions for peer resistance?
• Prophylactic treatment to prevent alcohol
  remission?
• BUT . . .
• Postponing treatment means potentially never

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Treating Tobacco Dependence in Recovering
Alcoholics

• Keep tobacco use on the problem list
• Motivate every few months using personal risks
  and discussing barriers
• Utilize past success strategies
• Associate with non-tobacco using friends
• Consider an ex-tobacco user as a sponsor

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Treating Tobacco Dependence in Recovering
Alcoholics

• Recommend proven therapies
• NRT
• Bupropion
• Varenicline
• Behavior Therapy
• Social Support
• Monitor frequently for relapse
• Let patient decide the timing