Smoking remains the chief preventable cause of premature disability and death in the United States. Smoking rates average 25 percent in the general population 1 but increase to 80 to 95 percent in chemically dependent persons. 2 Recovering from alcoholism.
Epidemiologic studies 3 –, 6 suggest that current and former alcoholic adults are at greater risk for some deleterious health effects of smoking, particularly cancer and cardiovascular disease, than are members of the general smoking and nonsmoking populations. A recent study on mortality following inpatient addiction treatment 7 found that patients previously treated for alcoholism or other drug dependence had a significantly higher cumulative mortality rate at 20 years (48.1 percent) than persons in the general population (18.5 percent). Since the causes of these deaths were more often related to tobacco (50.9 percent) than to alcohol (34.1 percent), the study concluded that “,nicotine-dependence treatment is imperative in such high-risk patients.”, 7
Until relatively recently, few studies had examined the effects of simultaneous treatment of multiple addictions. Smoking was generally considered more socially acceptable than other forms of substance use. For a long time, in fact, nicotine was not even considered addictive. The use of tobacco products was also perceived as being less disruptive to society than other forms of chemical dependence. Furthermore, most staff members in chemical dependency treatment centers were recovering alcoholics or problem drinkers who still smoked. 8, 9 Most importantly, traditional recovery folklore emphasized handling “,one thing at a time,”, based on the rationale that smoking cessation is stressful and likely to endanger sobriety.
As early as 1983, however, a positive relationship was found between smoking cessation during alcohol treatment and the chance of maintaining sobriety. 10 The findings of this study suggested an additive or synergistic effect when smoking and alcohol addictions were addressed simultaneously. Other recent research studies and review articles have supported these findings. 11 –, 16
Recovery from alcoholism timeline
A model illustrating smoking cessation activities for use with patients in alcohol recovery is presented in this article. The model consists of an algorithm for determining the patient's stage of readiness to change smoking behavior, 17 strategies for interventions appropriate for each stage and a counseling technique that can enhance patient motivation. 18 This model follows the clinical practice guidelines of the Agency for Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human Services. 19
Assessing Readiness to Change
In the readiness-to-change model, smoking cessation is viewed as a process of change with five stages: precontemplation, contemplation, preparation, action and maintenance. Research has suggested that the progress patients make following interventions for behavioral change tends to be a function of their pretreatment stage of change. 17 When a smoker's stage of readiness to change is known, messages can be tailored to the appropriate goal for that patient's condition.
An algorithm for assessing stage of readiness to change is presented in Figure 1. 17 The question “,Are you currently using tobacco?”, is in accordance with the clinical practice guidelines of the AHCPR. According to these guidelines 19 and supporting research, 20 every patient's current tobacco-use status should be identified at every office visit, and all smokers should be offered smoking cessation treatment at every visit. It is especially important to use these strategies with recovering alcoholic patients, since these persons have been found to be at increased risk for tobacco-related illnesses. The other questions in the algorithm assess the patient's stage of readiness to change smoking behavior by identifying current intentions and previous actions.
Once the smoker's stage of readiness has been identified, the strategies for that stage can be implemented ( Table 1 ). These activities are designed to facilitate patient movement from his or her current stage to the next stage, with the eventual goal being long-term smoking cessation. The activities themselves are a mix of proven smoking cessation techniques and Alcoholics Anonymous' 12-step activities with which the patient is likely to be familiar. Drawing a parallel between the patient's successful alcohol recovery and his or her tobacco addiction allows smoking cessation to be redefined in a way that is familiar to the patient and may increase the possibility of successful cessation. 21