Understanding the

Impact of Tobacco
on Recovery
Helping Treatment Professionals Move in Their
Stage of Change Regarding Tobacco-Free
Substance Abuse Treatment

Elizabeth Libby Stuyt, M.D.

Circle Program
Colorado Mental Health Institute at Pueblo
Pueblo, Colorado
 Treatment philosophies
historical perspective
Prior to 1970s drug and alcohol problems
were treated separately.
1974 National Drug/Alcohol Collaborative
Project (Gardner, 1980, DHEW Pub).
All drugs of dependence need to be
addressed in same setting to improve
abstinence rates.
Only drugs not included nicotine,
caffeine.
Relapse rates after
treatment

Relapse rates over

the first year after
treatment are
remarkably similar
for different drugs
of abuse (Hunt,
Barnett and Branch
1971, J Clin Psych,
27, 455-456)
Effect of concomitant drug
use on relapse
It is well documented in the smoking
cessation literature that alcohol use is a
relapse factor for resuming tobacco use
There has been no systematic
investigation into whether tobacco use
is a relapse factor for resuming alcohol
or other drug use however, there is
evidence that this may be the case. Reid
et al. Drug Alcohol Dependence 1998; 49:95-104;
Frosch et al. Exp Clin Psychopharm 2000;8:97-103.
 Frosch et al. Exp Clin
Psychopharm 2000;8:97-103
 Support that stopping
tobacco use aids in recovery
Alcohol abusers who had quit smoking
prior to treatment had a more successful
outcome than those who continued to
smoke (Miller et al. 1983, Addictive
Behaviors, 8, 403-412).
Higher abstinence rates in recovering
alcoholics who successfully quit smoking,
compared to those who continued to
smoke (Bobo et al. 1987, Addictive
Behaviors, 12, 209-215).
 Common Rationalizations
for not Providing Tobacco-
free Treatment
Its too stressful to stop everything at
once
You cant make some one stop smoking
It may cause patients to relapse
There are no immediate consequences
We may lose patients to other facilities
where they can smoke
Reasons to address tobacco
in treatment in the same
fashion as alcohol or other
drugs
Most programs address all other drugs
of dependence at the same time
80 95% of patients with substance
abuse use tobacco on a daily basis
Tobacco use is one of the leading
causes of chronic disease and mortality
Nicotine is a highly addictive drug
High relapse rates after treatment may
be related to ongoing tobacco use
 Smoke free versus
Tobacco free
Most programs follow the JCAHO directive
of smoke free in-doors but still allow
patients to smoke out-doors.
It is easy to not use when drugs and
alcohol are not available in a controlled
environment, but have patients really
accomplished any behavioral change when
they continue to practice addictive
behaviors with tobacco because it is
available?
 Rationalization # 1
Tobacco is not a real drug, its
just a habit.
Studies of the pharmacological effects

of nicotine indicate it functions in a

fashion similar to other drugs of abuse
in the brain (Henningfield, 1984;
Schelling, 1992; Rosecrans & Karan,
1993; and Pontieri et al., 1996).
Tobacco use is also a habit involving

a behavioral dependence similar to

that found with other drugs of abuse.
 Rationalization # 2
Quitting tobacco may cause
patients to relapse to the use of
drugs or alcohol.
Rather than causing patients to relapse
to drugs or alcohol, quitting tobacco use
serves to enhance sobriety. (Bobo et al.,
1986; Hurt et al., 1994; Martin et al.,
1997; Bobo et al., 1998).
There is also more evidence that tobacco
use can trigger cravings for and relapse
to other drugs and alcohol. (Stuyt, 1997;
Reid et al., 1998; Frosch et al., 2000).
 Rationalization # 3
Its too stressful to stop
everything at once.
No one has documented what is
too stressful.
In our experience, it is easier to stop
tobacco use in treatment rather than
outside the hospital after treatment.
Patients frequently report that they
wish they had stayed quit because it
was harder to quit tobacco outside
the hospital.
 Rationalization # 4
Tobacco use has no immediate
consequences.
It is true that there are no significant
immediate consequences to tobacco
use, but there are multiple long-term
consequences that are often deadly.
Tobacco is known to be a major cause
of premature death in patients with
substance abuse disorders who
achieve sobriety but do not stop
tobacco use (Hurt et al., 1996).
 Rationalization # 5
We will lose patients to other
treatment centers where they
can smoke.
If all treatment centers were tobacco
free this would be a non-issue.
If the decision to allow tobacco use
in treatment is based on the
institutions financial bottom line
and not what is best for the patient
does this say anything about the
integrity of the treatment program?
 Rationalization # 6
We cant make people quit
smoking if they dont want to
quit.
This is absolutely true.
When did treatment become about
making someone do something?
Treatment, especially inpatient and
residential, is about providing a drug
free environment where patients have
an opportunity to learn more about
their disease and consequences of their
behavior and practice new behaviors to
begin the process of recovery.
 Questions that need to be
addressed
The concern is not just whether
ongoing tobacco use is a relapse
factor for alcohol or other drug use?
But, based on what we now know
about the neurobiology of drugs of
abuse, does someone who is
continuing to use tobacco on a daily
basis optimally retain what they
learn in substance abuse treatment?
 Neurobiology
How do drugs work in the
brain?
 The Reward Pathway
Located in the limbic system
functions to monitor internal
homeostasis, mediate memory, mediate
learning and experience emotion
Includes the hypothalamus, amygdala,
hippocampus, nucleus accumbens
(NA), the ventral tegmental area (VTA),
locus ceruleus and the prefrontal
cortex
The Reward Pathway
 The Reward Pathway
Dopamine is the primary
neurotransmitter of the reward pathway
All drugs of abuse increase dopamine
levels in the brain reward pathway
although they often act through
separate mechanisms
Drugs that are not abused have no
effect on dopamine concentrations in
the reward pathway
 Natural Rewards Elevate Dopamine
FOOD
Levels SEX

DA Concentration (% Baseline)
200 200
NAc shell
% of Basal DA Output

150 150

Copulation Frequency
100 100
15

Empty 10
50
Box Feeding
5

0 0
0 60 120 180 ScrScr Scr Scr
BasFemale 1 Present Female 2 Present
Time (min) Sample 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Number
Mounts
Intromissions
Ejaculations

Source: Di Chiara et al. Source: Fiorino and Phillips

 Effects of Drugs on Dopamine Levels
1100 Accumbens AMPHETAMINE Accumbens
COCAINE
1000 400
% of Basal Release

% of Basal Release
900
800 DA
DA 300 DOPAC
700 DOPAC HVA
600 HVA
500 200
400
300
200 100
100
0
0 1 2 3 4 5 hr 0
0 1 2 3 4 5 hr
Time After Amphetamine Time After Cocaine

250
NICOTINE 250 Accumbens MORPHINE
% of Basal Release

% of Basal Release
Dose (mg/kg)
200 Accumbens
200 0.5
Caudate 1.0
150 2.5
150 10
100
100

0
0 1 2 3 hr 0
0 1 2 3 4 5hr
Time After Nicotine Time After Morphine

Source: Di Chiara and Imperato

Percent of those ever using
a drug who become
addicted
Biology/GenesandEnvironmentPlay
KeyRolesinVulnerability
Biology/Genes
Biology/
Environment
Interaction
Environment

DRUG

Addiction
Rats exposed to nicotine as adolescents
self-administer more nicotine than rats
exposed as adults Levin ED et al.
Psychopharm 2000;169:141-149
Learning Processes Underlying
Drug Addiction (N. White, 1996)
Amygdala-NAc (Incentive) promotes
approach to and interaction with drug related
cues (produces behavior unconsciously)
Caudate-Putamen (Habit) promotes
repetition of behaviors performed in the
presence of drug-related stimuli (produces
behavior unconsciously)
Hippocampus (Declarative) promotes
focusing of cognitive processes on drug
related situations (conscious)
 Glutamate Signaling
The amygdala, hippocampus and
frontal cortex talk to the reward
pathway by releasing glutamate
Changes in sensitivity to glutamate
enhance the release of DA from VTA to
NA, promoting CREB and delta fos B
Strengthens pathways that link
memories of drug taking with reward -
LTP
 Addictive Drugs and
Stress Increase
Sensitivity of DA Cells in
Mice (Saal et al. Neuron
2003;37:577-582)
 Brain Development
Human brains continue to develop after birth
and are not fully developed until late
adolescence/early adulthood
Amygdala is on-line at birth
Hippocampus is on-line about 18 months of
age
Prefrontal cortex (judgment) not fully
developed until late adolescence/early
adulthood
Use of drugs/alcohol can impede development
 Functions
Reward pathway NA GO system
Middle Prefrontal Cortex STOP
system
Amygdala warning system
Hippocampus episodic new
memory and learning, salience
Neurons that are wired together
fire together
 Effects of Drug Use on
the Hippocampus
Drugs of abuse are potent negative
regulators of adult neurogenesis in
the hippocampus
Chronic administration of opiates,
THC or ethanol decrease
hippocampal function, decreasing
ability of adult brain to adapt to new
information
 Possible Negative Effects of
Nicotine on Memory and
Cognition
Nicotine self-administration in rats profoundly
decreases, in a dose dependent fashion,
neurogenesis and increases cell death in the
hippocampus (Abrous et al. J Neuroscience 2002;22:3656-
3662)
Steeper decline in IQ seen in smokers than non-
smokers between 11 and 64 years of age (Whalley et
al. Addictive Behaviors 2005;30:77-88)
Adolescents who smoke cigarettes show
impairment of memory and other cognitive
functions (Jacobsen et al. Biological Psychiatry 2005)
Brain recovery in abstinent alcoholic individuals
is affected by chronic smoking (Meyerhoff et al. 2006)
 Chronic Tobacco Use
Chronic cigarette smoking is associated
with increased brain atrophy in individuals
> 50 years of age
Active cigarette smoking is associated with
diminished neurocognitive performance -
domains include:
Executive functions (Razani et al. 2004)
General intellectual abilities (Deary et al. 2003)
Memory (Hill et al. 2003, Schinka et al. 2003)
Psychomotor speed and cognitive flexibility
(Kalmijn et al. 2002)
 Given the neurobiology of
all drugs of abuse, how can
inpatient treatment help?
By allowing the brain an opportunity
to heal and the hippocampus to
regenerate improving the patients
ability to adapt to new information
they are receiving in treatment
Providing a safe environment
removing patient from chronic
stress/abuse/trauma
Providing an environment free of all
addictive drugs, including tobacco
Treatment that Promotes
Neurogenesis
Enriched environment that promotes
physical activity and learning (Gage, Science
2000;287:1433-1438)
SSRI medication, Lithium, ECT,
Transcranial magnetic stimulation
(normalization of serotonin and glucocorticoid
dysfunction, activation of growth factor and cAMP
pathways)
Paroxetine increased verbal declarative
memory and hippocampal volume in
PTSD (Vermetten et al. Biol Psych 2003;54:693-702)
 My Experience
with Tobacco Free
Programs
 Study methods program #1
28-day private, non-profit,
hospital-based, in-patient
Chemical Dependence program
Prospective study - Comparison of all
patients admitted over two consecutive
years.
Year I patients were allowed to go outside
to smoke.
Year II patients were expected to
completely refrain from tobacco use during
treatment.
Both years - patients were given a great
deal of education regarding tobacco use
and encouraged to quit.
Patients did not refuse to enter
treatment because they could
not smoke
Year I Year II
Total
number
admitted
174 174
Followed
for one
year after
87 83
treatment
AMA
discharge
rate
22% 16%
 Demographic variables for
patients followed for one year
after treatment

Tobacco Users 72%

Male 72%

Caucasian 85%

Alcohol 56%
primary drug of
abuse
There was no significant change
in financial class of patients
admitted

40
35
30
Percentage

25 Year 1
20
15 Year 2
10
5
0

Medicare
Medicaid
Commercial
BC/BS

Private pay
Funding source
Significant difference in sobriety
rates between tobacco users and
non-tobacco users

Sobriety rates of tobacco users and non-tobacco

users followed for one year after treatment

100
percentage of patients

80
Non-tobacco users
60 N=54
40 Tobacco users
N=116
20

0
1 2 3 4 5 6 7 8 9 10 11 12
P<.0001
month
 Patients who were convinced to
quit tobacco use during
treatment
Sober
Total % for one %
year

Year I (n=68) 1 1.5 0 0

tobacco users

Year II (n=55) 6 10.9 6 100

tobacco users
 Study methods program #2
90-day, state supported, dual-
diagnosis, in-patient program at
the State Hospital
Comparison of all patients treated in the six
months before going tobacco free and the year
after going tobacco free.
In the six months before patients allowed to
go outside to smoke.
After going tobacco free patients were
expected to completely refrain from tobacco
use during treatment.
All patients were given a great deal of
education regarding tobacco use and
encouraged to quit.
No difference in demographics
before and after going tobacco
free
Six months
One year
before
Characteristic after tobacco
tobacco free
free (N=157)
(N=111)

Age (SD) 35.47 (9.8) 34.77 (9.0)

Percent Male 57% 60%

Percent
Caucasian
78% 77%
No difference in primary drug of
choice before and after going
tobacco free
Six months One year
Drug of Choice before after
tobacco free tobacco free

Alcohol 47% 47%

Cocaine 10% 14%

Polysubstance 17% 17%

 No difference in psychiatric
diagnoses before and after going
tobacco free
One year
Six months
Primary Psychiatric after
before
Diagnosis tobacco
tobacco free
free
Schizophrenia or
Schizoaffective D/O
15% 17%

Bipolar Disorder 25% 26%

Depressive Disorders 39% 31%

Tobacco use, program completion
and length of stay before and after
going tobacco free

Six months One year

Patient
before after
Characteristics
tobacco free tobacco free

Tobacco use 86% 82%

Program completion 61% 59%

Average length of 65.3

67.7 (27.8)
stay in days (SD) (29.0)
Successful completion of
program by tobacco use
Non-
Completed
Tobacco tobacco
Program
Overall users users
successfully
N=268 N=224 N=44

Yes 60% 58% 73%

No 40% 42% 27%

 In the six months prior to going
tobacco free - patients could use
tobacco while in treatment

Continued Attempted Quit in or Never

Completed
tobacco to quit before used
program
use tobacco treatment tobacco
successfully
59% 16% 12% 13%

Yes (N=68) 50% 72%a 85%a 73%a

No
49% 28% 15% 27%
(N=43)

a
p <.0001
 In the year after going tobacco
free - patients were expected to
refrain from all tobacco use

Continued Followed Quit

Completed tobacco use rules but tobacco in Never
program in spite of plan to use or before used
successfully rules tobacco treatment tobacco
41% 20% 24% 15%
Yes (N=93) 46% 56% 73%a 78%a
No
54% 44% 27% 22%
(N=64)

a
p <.0001
 Patients decision regarding
tobacco use before and after
program is tobacco free
One year
Six months
Decision regarding after
before
tobacco use after tobacco
tobacco free
treatment free
N=111
N=157
Plans to continue
tobacco
75% 61%
Quit using tobacco
with plans to remain 12% 24%
abstinent
Never used tobacco 13% 15%
 Conclusions
There are no down sides to creating
a tobacco free in-patient or
residential treatment program.
In a tobacco free environment, even
patients with very poor coping skills
are able to practice not smoking and
develop coping skills for this which
they can translate to behavior with
drugs/alcohol outside treatment.
 Conclusions
More patients are likely to quit tobacco
use in a tobacco free environment.
A tobacco free environment encourages
patients to move in their stage of
change regarding their own tobacco use.
A tobacco free environment helps the
patients brains to heal and improves
their cognition/ability to learn and retain
information.