Nicotine-Should We Give It Up With Our Other Drugs?

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It is very easy to be dismissive of nicotine.  We are aware of its' problematic use,  but we fail to to give it proper respect as a drug.  Its legal status, and its' familiarity, creates a tendency for us to minimize the significance of its use.

I am not going to discuss the health issues of smoking.  There are more complete discussions elsewhere in the internet.  Rather, I want to discuss the issues of tobacco use in relation to how it affects other drug use.

I recall, years age, when smoking was allowed on inpatient drug treatment units.  The counselors would evaluate the new clients while both clients and counselors smoked cigarettes.  "Give up alcohol" the counselor would say,  "Wait to give up cigarettes.  Only do one thing at a time."   However, I could never recall an instance where a patient drinking and using heroin or crack or pot was told to continue the other drugs because they should only concentrate on one thing at a time. 

And the assumption became a reality.  Patients are convinced that they should wait to give up cigarettes.  After all, many smokers live and work in society without seeming to be intoxicated.  They may be putting their health at risk, but they are not real addicts.  They are reliable and could accomplish all they need to do for work and home.  Wouldn't attempting to give up cigarettes with other drugs put this at risk by increasing the risk of relapse with their other drugs?

What do the studies show?  Believe it or not, there are very few studies addressing this.  I am not a person given to conspiracies but there is a curious absence of desire to study whether ongoing nicotine use increased or decreased withdrawal dyndromes from other drugs.  A curious lack of money and a curious lack of interest.

To be fair, these studies are hard to do.  The best studies are double-blind studies where neither the patient nor the researcher knows whether any  patient is getting the intervention or a placebo.  How do you do a double-blind study in which a patient could not know they were smoking?  

So what do we know?  We know that the heaviest smokers are more likely to drink.  We know that active alcoholics who are also smokers are almost certainly going to continue to smoke.  We know that lab animals, exposed to nicotine, are more likely to drink. 

However, none of these situations address the real question.  That is: Does stopping tobacco use early in abstinence make us more or less likely to relapse with our drug of choice.

The best studies have focused on encouraging patients to stop smoking.  Forcing the issue has been associated with poor outcomes.  Most studies set up a smoking intervention group.  These interventions encourage smoking cessation- some offered medications and others did not.  

The groups that were encouraged to stop smoking had better success rates with alcohol cessation than the group  where smoking cessation was not stressed. 

On particularly good study, (Burling et al) showed a 10% nicotine abstinence rate in the intervention group (vs. none in the usual care group).  The patients who stopped smoking were twice as likely to have maintained abstinence as those who continued smoking. 

When substances, other than alcohol are looked at, the results are even better.  This includes studies with  adolescent populations.  Also, in those specific studies where smoking cessation medication was used, we also saw improvement in total abstinence rates.

There was one single study where patients had increased alcohol cravings while giving up tobacco, but this is the sole conflicting study.

I encourage all my patients to stop smoking.  It only makes sense.  The mechanism that leads to nicotine craving is a relatively low level of dopamine activity.  Each time we smoke, our dopamine level becomes low 1-2 hours later and we want another cigarette.  However, the mechanism of cocaine and other stimulant cravings is also low dopamine.  How does  a smoker, trying to get off drugs, know what to crave for when his dopamine level drops?

I have also had patients, given Chantix for smoking, who noted fewer cravings for their substance of choice.  It is to be noted that there have not been any studies using Chantix for smokers in early recovery.  If my own office experience is representative, than this would significantly improve both tobacco and over-all abstinence rates.

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