America is in the throes of an opioid crisis—and yet, it could be argued that tobacco is still a greater killer. About 64,000 people died of opioid overdose fatalities last year, while cigarette smoking causes more than 480,000 deaths annually in the United States.
Though cigarettes have become more stigmatized over the years, smoking rates remain high, especially within drug treatment communities. Also, people with mental illness and substance use disorders are two to four times more likely to smoke tobacco, with smoking prevalence rates at 40.1 percent for those with mental illness and 63.6 percent for those with substance use issues. One 2014 study found that about half the patients involved who suffered from schizophrenia, depression, and bipolar disorder actually ended up dying of a tobacco-related disease. People with mental health issues tend to live with addiction, and those who live with addiction are more likely to have a mental illness—this is called a co-occurring disorder. It's important to identify because a mental illness might change how a person is treated for a substance abuse disorder.
The study—which involved over 590,000 adult participants—also found that drug users who smoke cigarettes are four times more likely to die prematurely than those who don't smoke. The research reflects that tobacco smoking is the number one cause of death in people with mental illness and substance addiction, with about 200,000 tobacco-related deaths every year within this population. Moreover, this demographic consumes 44 percent of all cigarettes.
Unfortunately, it's common in drug treatment to focus only on quitting the substance that poses an imminent threat, such as heroin. "There is a benefit to focusing on the most immediate crisis, and you want to keep them in the treatment process," explains Christy Parque, president and CEO of the Coalition for Behavioral Health in New York City. "However, the approach for our providers is to focus holistically on the patient, integrating protocols for asking people about their smoking, advising them on the risks of tobacco to their health, and then figuring out their willingness to seek treatment for tobacco."
There is no research indicating that simultaneously quitting tobacco and another substance interferes with the treatment of mental illness or substance abuse, says Luis Torres, who works in the department of population health's section on tobacco, alcohol, and drug use at NYU Langone Health. In fact, he says, there’s evidence that suggests the opposite.
Smokers who quit during addiction treatment have a 25 percent increased likelihood of long-term abstinence from alcohol and other drugs. "Research looking at patients concurrently receiving mental health treatment have found that smoking cessation did not exacerbate depression or PTSD symptoms or lead to psychiatric hospitalization or increased use of alcohol or illicit drugs," Torres says. "The bottom line [is] smokers should be encouraged to quit regardless of whether or not they are in active treatment."
While treatment centers have historically not always been supportive of patients quitting cigarettes and drugs simultaneously, the norms are beginning to change with greater acknowledgment that treating tobacco addiction improves life expectancy for people with mental illness and substance use disorders, Torres says. Moreover, nicotine can be a neurological trigger, leading to further drug use if the patient is accustomed to getting high and smoking cigarettes together.
"There is research that shows that opioids and nicotine transmitter systems interact in important ways to modulate the effect of these drugs. This means that nicotine can prime the use of other drugs and vice versa," explains Donna Shelley, associate professor of medicine in the department of population health at NYU Langone Health and director of NYC Treats Tobacco. "It makes sense that if you treat opioid addiction—but don't treat nicotine addiction—the continued use of nicotine will increase risk of relapse into other drug use." This could be the theory behind the research that points to how quitting cigarettes and drugs together can help patients stay abstinent from both.
Torres points to New York state as an example of how policy change can help substance abuse treatment: Since 2008, all state licensed treatment sites have been required to be tobacco free for both staff and patients, and to provide tobacco cessation services. But outside New York it's much different. Only about a quarter of mental health treatment facilities offer services to also quit smoking. According to a 2016 survey of substance abuse treatment services in America, only 64 percent screen for tobacco use and only 47 percent offer smoking cessation counseling. Even fewer—less than 27 percent—offer nicotine replacement therapy, while only 20 percent provide non-nicotine medications to help a patient quit smoking.
"I'm a big proponent of harm reduction for nicotine addiction [versus abstinence only]," Shelley says. "With cigarettes, we've been so puritanical about it." Anything that helps a patient cut back on tobacco is the goal, whether it's nicotine replacement therapy, e-cigarettes, smoking fewer cigarettes, and so forth. "Most smokers, including opioid-addicted smokers and others with drug use problems, want to quit smoking," she adds. "It's expensive and bad for your health, especially when you're trying to [stop using.]”
Quitting one or the other, or both at the same time, means a patient will experience withdrawals no matter what. "Withdrawals hurt. They're horrible, you get cranky and irritable, or you're nauseated," says Beth Covelli, senior manager at NYC outpatient services with the organization Outreach. "If you're withdrawing from opiates, you're already having those symptoms. If you quit smoking you have those symptoms. You might as well get it over with in one shot."
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