Incorporating Smoking Cessation Into Substance Use Disorder Treatment
The CDC has a page discussing the Burden of Cigarette Use in the U.S. which includes statistics and evidence behind the use of cigarettes. Although smoking is the leading cause of preventable death in the United States, an estimated 12.5 percent of US adults were currently smoking cigarettes in 2020. Among adults in early recovery from alcohol and substance use disorders, smoking rates are between 65–85 percent. Although there is strong evidence supporting smoking cessation efforts among people recovering from alcohol and substance use disorders, health care providers often fear that smoking cessation may cause people in treatment to return to substance or alcohol use, and therefore may not offer a comprehensive treatment plan for tobacco use disorder- this is a missed opportunity.
A recent Cochrane Review looked at effectiveness of smoking cessation interventions for patients who were in treatment for or recovery from substance use disorder (SUD). The meta-analysis found that pharmacotherapy alone and pharmacotherapy plus counseling were effective for tobacco cessation among individuals in treatment for SUDs. Counseling interventions without pharmacotherapy were not effective. There was no evidence that smoking cessation interventions affect abstinence rates from alcohol or other drugs.
Patients who are receiving opioid use disorder treatment in office-based settings often have frequent contact with the clinic and clinic staff. These regular visits in primary care can be great opportunities to discuss smoking cessation and offer pharmacotherapy. When available and a patient is interested, counseling for smoking cessation can be offered in addition to pharmacotherapy.
Multiple FDA-approved pharmacotherapies for tobacco use disorder exist. A separate meta-analysis from the National Library of Medicine is comparing all pharmacotherapies for smoking cessation among the general population found that Varenicline led to the best odds of quitting as when used on its own, and outcomes were similar to combination nicotine replacement therapy (NRT), the use of two or more forms of nicotine replacement (e.g., a patch and the gum). Outcomes for bupropion and single NRT were better than placebo, but they were not as effective as Varenicline.
Some, but not all, primary care clinics will have smoking cessation counseling available on site. Even if your clinic does not have this capacity, there are a variety of phone-, web-, and app-based resources available for patients. For example, some states run their own Quitlines, which can help patients pick a quit date and receive individualized coaching. The Quit For Life website offers individualized coaching, online live chat, and free nicotine replacement therapy for people older than 18 years of age and who live in the following states as well as Guam and Washington, D.C.: AK, CT, DE, GA, FL, IN, ME, MO, MS, NC, NJ, NM, OK, SC, TX, VA, WA, WI. They also can assist patients from other states to find available resources in their home state. Finally, there are a growing number of smartphone apps that can provide patients with individuals and group support related to smoking cessation. iCanQuit is one example of a free smartphone app that is associated with higher rates of cessation.
Most primary care clinics already offer pharmacotherapy for smoking cessation. Because people who use substances and alcohol are significantly more likely to smoke than the general population, it is critical that smoking cessation resources are available and offered to individuals engaging in SUD treatment. Pharmacotherapy is essential to support smoking cessation in this population, and counseling services and cessation websites and apps can be helpful adjuncts.