Introduction

Most alcoholics or drug addicts have several addictions, and smoking is the most common other addiction by far. 

Many alcoholics in recovery do not realize that their cigarette smoking is probably an even greater threat to their health and survival than their drinking was.  Did you know that more alcoholics die of diseases related to smoking than of diseases related to drinking?  Smoking has also been linked to a long series of health problems, such as rheumatoid arthritis and  osteoporosis-related hip fractures, in addition to cancer and heart disease.

New studies have shed much light on cross-addiction between nicotine and alcohol.  Nicotine increases the craving for alcohol. For many alcoholics, smoking is also a behavioral trigger for drinking, and getting clean from cigarettes is a major step toward reducing cravings for alcohol.   Many alcoholics in recovery have successfully quit smoking after they quit drinking.  Studies have shown also that alcoholics can quit drinking and smoking at the same time, and modern treatment centers are increasingly based on this principle. 

Before the 1930s, treatment of alcoholism and drug addiction commonly also included treatment of nicotine addiction.  Smoking was generally viewed as a contributing factor in alcohol and drug relapses.  But with the rise of Alcoholics Anonymous (AA), concern with smoking as a recovery issue faded into the background.  Bill W., the  co-founder of AA, was a chain smoker who died of emphysema. Today, the treatment industry and the recovery community are returning to the original positions.  Smoking is recognized as a drug addiction on a par with other substance addictions, and is being treated accordingly.

For the recovering alcoholic even more than for the ordinary smoker, kicking cigarettes may be a question of life or death.  If you're an alcoholic or drug addict in recovery who wants to quit smoking -- no matter when or how -- this page is a page of support for YOU.

• More than 90 per cent of alcoholics smoke, compared to fewer than a third of non-alcoholics. 
• Alcoholics smoke more cigarettes per day than do nonalcoholic smokers. 
• Alcoholics are more likely to smoke mentholated cigarettes. 
• The number of cigarettes a person consumes rises in tandem with the number of drinks consumed. 
• Almost every smoker who smokes more than two packs a day is also an alcoholic. 

Source: T. Bien and R. Barge, Smoking and Drinking, a Review of the Literature (1990), International Journal of the Addictions 25(12). 

Numerous studies have suggested a common link in addiction by showing that people addicted to one substance are more likely to be addicted to others. The strongest connection is between tobacco and alcohol. Smokers drink twice as much alcohol as non-smokers--and their risk of drinking too heavily is also twice that of non-smokers. One study found that alcoholism is 10 to 14 times more prevalent among smokers. And, while the percentage of smokers has dropped to 30 percent of American adults, it is unchanged among alcoholics.

Source:  Scientific American, 11/24/97

New research indicates that nicotine causes the brain to crave alcohol.  Led by Toronto's Dr. Dzung Anh Le, a study on rats by Canadian and U.S. scientists has found that nicotine use increases alcohol consumption, and the two addictions may work hand in hand. With this in mind, trying to quit both habits at once, painful as it may be in the short-term, may well be a better long-term strategy.

Another study on rats found that nicotine seems to inhibit the initial effects of alcohol, so that the animals drank more alcohol to compensate.  Source.  This is consistent with other studies showing that nicotine interferes with the effect of other psychoactive chemicals. Sources.

National Institute on Drug Abuse researchers have released two studies that found that craving for nicotine appears to be linked to increased craving for illicit drugs among drug abusers who also smoke tobacco. The two studies, said NIDA Director Dr. Alan I. Leshner, "add very strong behavioral evidence to other research that suggests common characteristics and interactions between tobacco use and opiate and cocaine use. They also suggest that smoking cessation programs should be offered as part of other drug treatment programs." In one of the studies, researchers found that the amount of cocaine and heroin use was directly related to the level of tobacco use. "The more cigarettes smoked, the more likely the person was to use illegal drugs," said a researcher.  

On initial hospital admission, 75% of the patients listed themselves as current cigarette smokers, 8% were former smokers, and 3% smoked pipes or cigars. In 1994, Dr. Hurt's team checked the program's records to determine the current status of those patients and to obtain death certificates for any who had died.

Death certificates obtained for 214 of the 222 deceased patients indicated that the cause of death was tobacco-related in 50%, and alcohol-related in 34%. Dr. Hurt says the cumulative mortality from smoking among substance abusers was 48.1%, about 2 1/2 times the expected rate. This suggests to Dr. Hurt that most persons undergoing treatment for alcoholism should undergo treatment for nicotine dependence, as well.

Source: Journal of the American Medical Association, 1996; 276:1097-1103.

Source: "Recovery Community: Have We Let Smoke Get in Our Eyes?"  by Marlene M. Maheu, Ph.D.

AA co-founder Bill W. smoked cigarettes.  He quit in the last year of his life, but it was too late for him.  -- Source:  Slaying the Dragon (see review), p.  139

The other co-founder of AA, Dr. Bob, was a cigar smoker.  He died of throat cancer.  Source: Smoke Screen, by Bernice Order-Connors LSCW, CADC, CPS, Professional Counselor Dec. 1996.

CAMBRIDGE, Mass. (AP) - Caroline Knapp, who chronicled her struggles with alcoholism in the memoir "Drinking: A Love Story," died Tuesday after a battle with lung cancer. She was 42.

In her memoir, Knapp detailed the contradictions in her life as a "high-functioning alcoholic."

Knapp was an Ivy League graduate and successful journalist who by all appearances had her life in order. But underneath, she was filled with the lies and self-loathing that come with addiction.

Critics praised the book, published in 1996, for its stark honesty, and it was on The New York Times best-seller list for several weeks.

"Since that time many medical writers and journals have unequivocally classed smoking, and particularly cigarette-smoking, as an addiction for many people. Some physicians compare the addictive qualities of nicotine to heroin and barbiturates but others maintain that for many people cigarettes can be even more addictive than heroin, barbiturates or alcohol. [...]

"The 1988 Surgeon General's report, The Health Consequences of Smoking: Nicotine Addiction found that nicotine is a powerful pharmacologic agent that acts in the brain and throughout the body. Nicotine readily crosses the blood-brain barrier and accumulates in the brain shortly after it enters the body. Once in the brain it interacts with specific receptors and alters brain energy metabolism in a pattern consistent with the distribution of specific binding sites for the drug."

ASH - ACTION ON SMOKING AND HEALTH

For a comprehensive and up-to-date summary of current scientific knowledge about smoking, see Research Report on Nicotine Addiction (1998) by the National Institute on Drug Abuse (NIDA).

For perspectives from an interdisciplinary conference on the state of the art in smoking research, bringing together neuroscientists and social scientists, among others, see the Robert Wood Johnson Foundation's Report 2000, Ch. 8.

MAO B (1 of 2 isozyme forms of the enzyme) is involved in breaking down dopamine, a neurotransmitter that plays a role in movement as well as in feelings of pleasure, including those associated with most substances of abuse, including cocaine, amphetamines, heroin, alcohol, and nicotine.

The finding, researchers say, may help explain the strong association found between smoking and depression.  It also suggests that cigarettes are a "gateway drug" to other addictive substances, since the effects in the brain are analogous.

The findings also cast doubt on much previous addiction research.  Because most substance abusers smoke, "it's very difficult to sort out what effects are caused by smoking and what effects are caused by the abused substance,"  said chemist Joanna S. Fowler, PhD, one of the authors of the study.

--Based on Joan Stephenson, PhD , in JAMA, April 24, 1996

See also, "Like Other Drugs of Abuse, Nicotine Disrupts the Brain's Pleasure Circuit" NIDA Notes (13:3)

• Smoking kills off women's egg supply and may be a causative factor in infertility and early menopause, according to research published in Nature Genetics in July 2001. 
• Women who smoke during pregnancy may pass on cancer to their unborn child.  Click.

• Smoking may lead to increased problems with rheumatoid  arthritis. In a study published in Annals of the Rheumatic Diseases, University of Iowa researchers, led by Dr. Kenneth Saag, assistant professor of internal medicine, report that smoking is a significant, modifiable risk factor for the severity of rheumatoid arthritis, a disease that affects more than two million Americans. Their findings imply that quitting smoking may influence the severity of the disease.

• Smoking also appears to be linked to hip fractures in older women. According to a report in the British Medical Journal, post-menopausal bone loss was greater in current smokers than non-smokers, bone density diminishing by about an additional 2 percent for every 10-year increase in age, with a difference of six percent at age 80. In current smokers relative to non-smokers the risk of hip fracture was similar at age 50 but greater thereafter by an estimated 17 percent at age 60, 41 percent at 70, 71 percent at 80, and 108 percent at 90.

• "Low-tar" cigarettes don't help.  The published "tar" ratings are based on unrealistic laboratory conditions, and in real life smokers get as much tar and nicotine from the "low-tar" brands as from others, researchers in London have found.  Source.  If you think you're lowering your risk by smoking "lights," you've been seriously misled.  Read a comprehensive review of the evidence on that issue.

Effects Causally Associated with ETS Exposure

• Developmental Effects
  • Fetal Growth: Low birthweight or small for gestational age
  • Sudden Infant Death Syndrome (SIDS)
• Respiratory Effects
  • Acute lower respiratory tract infections in children ( e.g., bronchitis and pneumonia)
  • Asthma induction and exacerbation in children
  • Chronic respiratory symptoms in children
  • Eye and nasal irritation in adults
  • Middle ear infections in children
• Carcinogenic Effects
  • Lung Cancer
  • Nasal Sinus Cancer
• Cardiovascular Effects
  • Heart disease mortality
  • Acute and chronic coronary heart disease morbidity

Effects with Suggestive Evidence of a Causal Association with ETS Exposure

• Developmental Effects
  • Spontaneous abortion
  • Adverse impact on cognition and behavior
• Respiratory Effects
  • Exacerbation of cystic fibrosis
  • Decreased pulmonary function
• Carcinogenic Effects
  • Cervical cancer

Because tobacco smoke harms others -- particularly the vulnerable lungs and hearts of children -- smokers who care about others will avoid smoking indoors where others may be breathing, avoid smoking in closed cars, and avoid smoking near doorways where people have to pass. 

Tobacco users also pay more for life insurance than non-users do -- a lot more. Typically, a smoker pays twice the price a non-smoker pays for life insurance, according to the Consumer Federation of America.

If you have it in mind to stop, pick a company that lowers premium prices for people who kick the habit. Some companies will reduce your rates after you've stayed off tobacco for a set period of time, usually between 12 months and 3 years. With others, you're permanently stuck at a smokers' rate -- so make sure you ask.

"If someone quits, they can request a policy change," said Jim Livingston, senior vice-president of underwriting for ING Life Companies. "We generally require that the person hasn't used tobacco in the past 12 months."  (Excerpted from CNN/Money 4/8/02)

Neuropharmacological Actions of Cigarette Smoke: Brain Monoamine Oxidase B (MAO B) Inhibition;  Cigarette Smoking and Major Depression;  Comorbid Cigarette and Alcohol Addiction: Epidemiology and Treatment; Tobacco, Alcohol, and Drug Use in a Primary Care Sample: 90-Day Prevalence and Associated Factors.  Click.

"Somewhere between then and the early 1960s when inpatient treatment programs began to develop, that concept was lost and the emphasis was on treating the alcoholism to the exclusion of other conditions. At that time, it was unlikely for alcoholics to be dependent on other drugs except nicotine. In the late 1970s and early 1980s, the demographics began to change and use of other drugs such as marijuana, cocaine, narcotics, sedatives, and tranquilizers was more commonly seen in alcoholic patients undergoing treatment.

"During this time of transition, the treatment community began incorporating the treatment for other drugs of dependence into their programs, except for nicotine. The major point of our study is that if the treatment community is concerned about the ultimate outcome for their patients (i.e., mortality), it is difficult to ignore nicotine dependence as a treatment issue."

Richard D. Hurt, M.D. JAMA Letters Sept. 11 1996

"Nineteenth and early 20th-century inebriety specialists ... waged a consistent attack on tobacco as a harmful and addictive substance and viewed smoking as a contributing factor in alcoholic and narcotic relapse.  [But] Modern addiction specialists took on the issue of tobacco only when the evidence of the harmfulness of smoking and the addictiveness of nicotine had become overwhelming....  

"By the late 1980s the addiction treatment field was going through a rather painful process of self-examination and self-confrontation related to its response to the nicotine addiction of the majority of its workforce and clients.  There were growing calls to look at the issue of smoking as an ethical as well as a clinical issue.  Growing numbers of programs went smoke free and began to state explicitly that they would hire only non-smoking staff.  Programs also began to combine treatment for smoking with the treatment for alcoholism and other drug addictions, and conduct these simultaneously."

William L. White, Slaying the Dragon: A History of Addiction Treatment and Recovery in America (1998), pp. 309-310. 

Treatment staff need to confront their own nicotine addiction or forfeit their integrity and credibility as addiction counselors.  Read Alcohol, Tobacco and Other Drug Use by Addictions Professionals: Historical Reflections and Suggested Guidelines, by William L. White (2006)

Source: "Nicotine," by Joy M. Schmitz, Nina G. Schneider, and Murray E. Jarvik, in Lowinson et al., Substance Abuse, a Comprehensive Textbook, 3rd. Ed. 1998, p. 286.

"There is no research support for the contention that alcoholics should not try to quit smoking at the same time they are attempting to quit drinking.  In fact, the research more closely supports the view that 'smoking and drinking are correlated behaviors; anything causing a reduction in one may be associated with a reduction in the other.'" 

Source: T. Bien and R. Barge, Smoking and Drinking, a Review of the Literature (1990), International Journal of the Addictions 25(12).

Alcoholics seem to develop a deeper dependence on nicotine and may have more difficulty quitting smoking than do non-alcoholics. A study in Alcoholism: Clinical & Experimental Research closely examined this association to see if smokers with a past history of alcoholism are more nicotine dependent than smokers with no problem drinking history.

 "There are many theories of why smoking and alcoholism go together," said John R. Hughes, professor of psychiatry at the University of Vermont and lead author of the study in a news release. "Some studies suggest that the same genes that predispose people to alcoholism also predispose them to smoking. Some have thought there is an 'addictive personality' that becomes addicted to many things, but research suggests this is not so."

 "Another idea is that since smoking stimulates and alcohol relaxes, smokers use alcohol to prevent over-stimulation from smoking and alcoholics use cigarettes to prevent sedation," he said. "Yet another idea is that those who become alcoholics are people who use substances for the drugs within them, for example, to get high or to cope with life. This theory would predict that alcoholic smokers use tobacco mostly for the nicotine in it."

 Using nicotine gum, Hughes' study examined if smokers with a past history of alcoholism would self-administer nicotine more often and in greater amounts than non-alcoholic smokers. They found that smokers with a history of alcoholism said they didn't enjoy nicotine more, but they did more often choose to use pure nicotine, and ingested greater levels of nicotine than smokers without this history.

"It may seem unusual," said Hughes. "In fact, many smokers state they can't understand their use of cigarettes because they feel they really don't get much out of it. Sometimes we can like something but not be able to express what it is we like about it."

Treatment centers may be one of the few places equipped to give drinkers the special help they may need to also quit smoking.

Treating multiple addictions at once does not seem to make recovery any more difficult. The treatment center at the University of Texas Medical School reports that since it became "smoke free" in 1991, it has observed no change in the rate of premature discharge, in the percentage of people who completed the program and in patient stress or unusual incidents. "It turns out it's not that hard to wean people from nicotine when it becomes the expectation of the program," say Terry Rustin, who heads the unit. 

Source: Scientific American, 11/24/97

There are two broad branches, the pharmacological and the behaviorist. The "patch," the gum, the nasal spray and the nicotine inhaler are methods of delivering nicotine to your system without smoking, on the theory that you will gradually wean off. 

Use of such nicotine replacements is vastly more effective if done in combination with some kind of behavioral therapy.  There are numerous behavioral approaches, often used together.  Common ones include tapering or fading, scheduling or timing, motivational enhancements via rewards and punishments of different kinds, relapse prevention, cue exposure, aversion therapy, and others. 

New medications for both nicotine addiction and alcoholism are on the way, now that scientists realize that addictions stem from much more than "an addictive personality" or weak will. The remedies being tested actually target the cascade of neurochemical events at the root of addicts' cravings.

Isradipine, a drug recently shown to reduce the desire for alcohol, is a calcium-channel blocker normally used to treat high blood pressure. The compound also appears to affect levels of dopamine in the brain's reward center. Similarly, a prescription antidepressant called bupropion, marketed commercially as Wellbutrin for depression and Zyban as a smoking cessation aid, seems to block smokers’ cravings by mimicking nicotine's ability to increase the amount of dopamine in the brain.

Recent experiments with a new medication, Rimonabant, suggest that this drug not only helps people quit smoking but also helps them lose weight at the same time.  Link.

There are numerous other approaches as well: nutrition, hypnosis, acupuncture, herbal teas, you name it.  There's undoubtedly a quantity of worthless and even harmful hype as well, so be alert.  Some methods are done alone, some in groups.  There are commercial programs, non-commercial programs, inpatient and outpatient programs, and there is a growing self-help literature. 

There are not yet, apparently, any programs aimed specifically at the sober alcoholic or drug addict who wants to quit smoking.  But then, as a person who has successfully quit drinking and/or drugging, you already know a lot about addiction and you have a head start!

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