Addiction Recovery
and Tobacco

A few words about the stats
in this presentation
• Some of the stats in this presentation may
appear to conflict.
• Some may disagree on the precise
numbers, but underscore the same point.
• Some focus on specific groups

Millions of Americans have
personally experienced the miracle
of recovery

Tobacco still touches too many of
our lives.

We all breathe a big sigh of relief
after escaping from AOD addiction

Recovery from tobacco is possible
and necessary.

We must redefine "full" recovery

Tobacco is addictive and
dangerous

Nicotine is among the most
addictive drugs.

Marijuana
• Lifetime use = 48.3%
• Lifetime dependence = 4.2%
• Capture rate = 9.1%

Alcohol
• Lifetime use = 91.5%
• Lifetime dependence = 14.1%
• Capture rate = 15.4%

Cocaine
• Lifetime use = 16.2%
• Lifetime dependence = 2.7%
• Capture rate = 16.7%

Heroin
• Lifetime use = 16.2%
• Lifetime dependence = 2.7%
• Capture rate = 16.7%

Tobacco
• Lifetime use = 75.6%
• Lifetime dependence = 24.1%
• Capture rate = 31.9%

Ask the experts
Two questions:
• How easy is it to get
hooked on these
substances?
• How hard is it to stop using
them?
John Hastings
In Health, 1990.

The results
• Nicotine 100
• Methamphetamine
(smoked) 99
• Crack 98
• Methamphetamine
(injected) 93
• Valium 85
John Hastings
In Health, 1990.

Relative Addictiveness
According to large Government surveys:
• Alcohol users, only 5 percent are regular.
dependent drinkers.
• Cocaine users, 8 percent become
dependent.
• Cigarettes, 90 percent of smokers are
persistent daily users, and 55 percent
become dependent.

Tobacco is a major killer.

A Vicious Killer
• Roughly 46 million Americans report regular
tobacco use
• Tobacco is responsible for approximately 1 in 5
deaths each year
• Half of lifelong smokers will die from smoking
• Women are now more likely to die from lung
cancer than breast cancer
• About 440,000 Americans die prematurely each
year from smoking, 13.2 years early for men and
14.5 for women

Comparative Causes of Annual
Deaths (in thousands)
450
in the United States 430
Number of Deaths (thousands)
400
350
300
250
200
150
100 81
41 30
50 17 19 14
0
AIDS Alcohol Motor Homicide Drug Suicide Smoking
Vehicle Induced
Source: CDC

Causes of Preventable Death
Michigan, 2002
0 2000 4000 6000 8000 10000 12000 14000 16000
Cigarettes
Secondhand Smoke
Auto Accidents
Suicide
Homicide
Drug Overdose
Alcohol
AIDS
Fires

Tobacco is a major disabler.

The great disabler
Tobacco is not only the leading
preventable cause of death, it
also wreaks havoc by causing
disabling disease that leave
thousands with severe and
debilitating chronic conditions

The Disability Toll
• The CDC estimates that at least 8.6
million Americans have serious smoking-
related lung diseases.
• Chronic bronchitis is the most prevalent
illness.
• For every person who dies from smoking,
20 more people suffer with at least one
serious illness caused by smoking.

Cancers Caused by Tobacco
• Mouth • Lung
• Tongue • Stomach
• Throat • Bladder
• Larynx • Kidney
• Leukemia • Pancreas
• Cervix

Diseases Cause By Tobacco
• Cataracts • Osteoporosis
• Gum disease • Emphysema
• Tooth loss • Infertility
• Rheumatoid • Impotence
arthritis

The Staggering Cost Burden
• A new CDC study shows smoking costs
the U.S. $150 billion each year in health
costs and lost productivity, 50% more than
previously estimated
• Annual economic costs in 1998 were
$81.9 billion in productivity costs and
$75.5 billion in excess medical
expenditures, according to the CDC report

Human and Health Care Costs
• On average, a smoker costs an extra
$1,623 in medical expenditures per year
• Estimates of U.S. health expenditures
attributable to smoking are around 14
percent
• Cost to a smoker: $3,393 annually, or
$7.18 per pack with 22 billion packs sold
per year

How big a problem is
tobacco in the United
States?

Good News
Total Population
60
Population Percentage
50
40
42.4
30
20 22.2
10
13.6
0
65
70
78
80
85
88
91
93
95
98
00
19
19
19
19
19
19
19
19
19
19
20
Current Former Never

From this…

From this…

To this…

What about us?

What about us?

The conventional wisdom about
recovery is wrong and
dangerous.

Arguments against addressing
tobacco in treatment and early
recovery

Arguments against addressing
tobacco
• “We don’t need to worry about it. Smoking
is on the decline.”
• “First thing’s first. We need to address the
problem that’s really going to kill them”
• “Tobacco and drug addiction/alcoholism
are really separate issues.”

Arguments against addressing
tobacco
• “Quitting smoking might increase the risk
of relapse” “It’s too much to do at once”
• “They’ll quit on their own”
• “They’re only hurting themselves”

Arguments against addressing
tobacco
• “They won’t come to treatment” “We’ll
have more ASAs”
• “They don’t want to quit.”
• “They won’t quit anyway” “It won’t make a
difference”

“Fewer people are smokers”
• 80% to 90% of alcoholics smoke nationally
• 90% of recent Dawn Farm admissions use
tobacco
• Only 23% of the Michiganders smoke
• Addicts and alcoholics smoke more
heavily

“We need to address what’s
really killing them.”

"Bill W. was lifted to the
podium in his wheelchair,
oxygen tank at his side.
He was dying of lung
disease. A brave,
relentless visionary gave
his last professional
address about alcohol
dependency, only to die
from lung disease related
to cigarette smoking. He
died from nicotine
addiction.“
Source: "Recovery Community: Have We Let
Smoke Get in Our Eyes?" by
Marlene M. Maheu, Ph.D.

He quit in the
last year of
his life, but it
was too late
for him.
Source: Slaying
the Dragon

Dr. Bob was a
cigar smoker.
He died of
cancer.

Cause of Death in
Recovering Alcoholics
120
100
Attributable 80
Deaths
60
40
20
0
Alcohol Tobacco Other
Hurt et al, 1995

“Less serious”
• 80% of all drug related deaths are due to
tobacco (Unwin, 1999)
• Addicts and alcoholics who continue to
use drugs and alcohol are more likely to
die of tobacco related illness than other
drugs or alcohol

“Less serious”
• The risk of mouth and throat cancer is 38
times greater for people who use tobacco
and alcohol (Blot, 1992)
• Alcoholics who smoke have significantly
increased risk of cardiovascular disease
(Abrams, 1996)

Separate issues?
• Heavy smokers have worse relapses
(Abrams, 1992)
• Heavy smokers are more likely to leave
treatment early (Kempf, 1996)
• Severity of tobacco use predicts poor
cocaine treatment outcomes (Patkar, 2003)

Separate issues?
• Smoking increased urges to use (Rohsenow,
2005)
• Significantly better recovery rates were
discovered for non-tobacco users (Stuyt, 1997)
• Continued smoking adversely impacted
treatment for marijuana dependence
(Sullivan, 2002)

Separate issues?
At Dawn Farm residential sites in 2007:
• Nonsmokers completed treatment at a rate
17% higher than smokers.
• Nonsmokers were in recovery at follow-up
at a rate 7% higher than smokers.

“Increase relapse”
“It’s too much to ask”
• Quitting smoking does not jeopardize
sobriety/treatment outcomes. (Bobo, 1987; Bobo
1998; Burling, 1991; Cooney, 2003; Hurt, 2003; Joseph, 1993; Metz,
2005)
• Clients who quit smoking were
significantly more likely to report
abstinence at follow-up (93% vs 62%)
(Joseph, 2005)

“Increase relapse”
“It’s too much to ask”
• Smoking cessation interventions were
associated with 25% increased liklihood of
long-term abstinence (Prochaska, 2004)
• Treatment of tobacco dependence
enhanced abstinence from drinking (Hurt,
2003)
• 48% of non-tobacco users maintained
sobriety for 12 months compared to 14%
of tobacco users (Stuyt, 1997)

“Significantly better recovery rates
were discovered for non-tobacco
users than tobacco users,
especially if the drug of choice was
a sedative, such as alcohol or
narcotics. Data presented here
support the theory that continued
nicotine use may be a relapse
factor for resuming alcohol use.”
Stuyt, 1997

“Increase relapse”
“It’s too much to ask”
At Dawn Farm residential sites in 2007:
• Smokers who expressed interest in quitting
were in recovery at a rate 7% higher than
those who were not interested.

“They’ll quit on their own”
• Nicotine dependence is more severe in
those with a history of alcohol
dependence (Marks, 1997)
• 0% to 12% of clients quit on their own
(Campbell, 1995; Joseph, 2005)
• Only 7% of alcoholic smokers were
successful in quitting, compared to 49% of
nonalcoholic smokers (DiFranza, 1990)
• Smoking increases following treatment.
(Connor, 1999)

“Only hurting themselves”
• Of nonsmokers who entered treatment,
15% had started smoking by 12 month
follow-up (Friend, 2004)
• Abstinence rates were lowest for those
who started smoking in treatment. (Kohn, 2003)
• Children of smokers are 2-3 times more
likely to become smokers
• Early smoking is a major risk factor for
substance use (Degenhart & Hall, 2001)

“Won’t enter tx”
“Increased ASAs”
• A smoke-free policy had no adverse effect
on treatment outcomes (Joseph, 1993)
• Heavy smokers were more likely to leave
treatment early. They leave smoking
programs at the same rate. (Kempf, 1996)
• Clients complained but didn’t leave at
higher rates (Kempf, 1996)

“Won’t enter tx”
“Increased ASAs”
• Census increased after initiation of no-
smoking policy (Kotz, 1993)
• No smoking policy had no impact on
numbers of patients seeking OP treatment
or number of sessions attended (Sterling, 1994)
• There was no increase in irregular
discharges, or reductions in smokers
entering treatment (Williams, 2005)

“They don’t want to quit”
• 46% were “very” or “moderately”
interested in nicotine treatment (Kozlowski, 1989)
• Nearly half had a “strong desire” to quit
smoking (Orleans, 1993)
• 93% believe treatment facilities should
help people quit smoking (McDonald, 2000)
• 46% of smokers admitted to DF residential
in 2007 said that they would like help
quitting

“They won’t quit”
• 6 weeks post-discharge 58% were
nicotine-free or had greatly reduced use
(Pletcher, 1993)
• Reduced tobacco use is associated with
improved treatment outcomes
• Reduced tobacco use is associated with
increased motivation to quit

We're more addicted to tobacco.
• Alcoholics smoke more cigarettes than
other smokers. (Batel, 1995; Burling, 1988)
• Alcoholic smokers had higher nicotine
tolerance that non-alcoholic smokers.
(Burling, 1988)
• Among heroin addicts, the average age of
smoking initiation was 13. (Clemmey, 1997)

Quitting tobacco improves our
chances of recovery.

The country is going tobacco free
and we're left behind.

Full recovery is possible. You
can quit tobacco.

Matt Statman CAC-M
Education Series Coordinator

Matt Statman CAC-M
Education Series Coordinator

 Withdrawal Symptoms
 Benefits of quitting
 How Can I Quit?
 How Can I Stay Quit?

Nicotine is a drug and there are withdrawal
symptoms when it is stopped.
 Feeling depressed
 Not being able to sleep
 Getting cranky, frustrated, or mad
 Feeling anxious, nervous, or restless
 Having trouble thinking clearly
 Feeling hungry or gaining weight

 First few days – dizziness, cough, runny
nose.
 A week or two later – headaches,
sleepiness or trouble sleeping, increased
phlegm, hunger, digestive changes.

Not everyone has these feelings.
You may have one or more. They
may last different amounts of time –
but remember they won't last
forever.

Immediate Benefits (0-48 Hrs)
 Blood pressure decreases
 Circulation improves - hands and feet
 Within 24 Hrs. chance of heart attack
decreases
 Smell and taste start to return (and you
smell better too)
 Feel good about it

Benefits (2 weeks – 9 months)
 Continued improvement in circulation and
lung function
 Decrease in fatigue, coughing, and
shortness of breath
 More money! (if you smoke a pack a day
about $1,600 in 9 months)

2006 Study
 “After one month of sobriety, recovering
alcoholics who smoked showed
significantly less improvement than those
who did not smoke in both brain function
and neurochemical markers of brain cell
health.” University of California

Longer Term
 After 1 year heart disease decreased to
about ½ that of a smoker
 Stroke risk reduced to that of someone
who has never smoked (5-15 years)
 Risk of lung cancer ½ of that of a smoker
(10 years)
 Decreased risk of cancer (mouth, throat,
esophagus, bladder, kidney, cervix,
stomach and pancreas)

More benefits
 At $6 a pack 1 pack a day you
save $2,190 a year
 5 years you saved $10,950
 10 years $21,900!

Tobacco Vs. Alcohol
The short-term effects of alcoholism may
appear more dangerous than those of
cigarette smoking. However, mortality
statistics suggest that more people with
alcoholism die from smoking-related
diseases than from alcohol-related
diseases (Hurt et al. 1996).

More motivation?
“Smoking can damage the blood
circulation system in the penis and
causes blockage in the blood vessels
and leads to ED. It also causes
reduction in sperm production,
damages normal development of
sperms, raises the opportunity of
stillbirth and deficiency in the
embryo, or even sterility.”
University of Hong Kong

It gets better!
 “Ex-smokers have 30% less risk of
having sexual dysfunction than those
who smoke 20 cigarettes or more per
day.” University of Hong Kong Study
 Numerous studies suggest that men
and women who quit smoking have
improved sexual functioning, measured
physiologically and subjectively (self-
reported.)

 Pregnantwomen
have healthier
babies!

 “Cold turkey” is the most common method of
quitting.
 American Cancer Society's “Cancer Facts and
Figures 2003” reported 91.4% of former U.S. adult
smokers quit “cold turkey” without other support.
 According to a recent study, about 78.3% of
people who try to quit do it “cold turkey.”
 About 5% of people who quit “cold turkey” remain
abstinent for a year.
 Smokers are more likely to quit if they stop
abruptly rather than trying to wean themselves
down.

 An overwhelming majority of people who
try to quit do it cold turkey.
 Only 5% of them actually stop for a year.
 But most people who quit permanently do
it cold turkey (just because of the sheer
volume)

 Help people change behaviors to support a
tobacco free lifestyle.
 Behavioral interventions have been proven
to increase success at tobacco cessation.
Most successful in combination with
medication.
 Since many recovering people are familiar
with 12 Step approaches to recovery,
utilizing this approach is also effective to
help recovering people initiate and maintain
tobacco abstinence.

Examples
Think of what triggers your tobacco use such as
first thing in the morning, after a meal, sex,
after the meeting, at social gatherings, while
meeting with your sponsor, after a difficult
conversation etc. - and develop a plan to avoid
or deal with these triggers.
Develop personal supports for quitting within the
recovering community . Find a “quit buddy,” or a
supportive non-smoker.

Behavioral Support
 Tobacco Cessation Support Groups
 Counseling (individual or group)
 Cognitive Behavioral Therapy
 Nicotine Anonymous
 Telephone Quit lines
 Online support

Smoking is a social activity and social
support is extremely important when
trying to quit.
Success at quitting is improved by a
smoke-free home and other environments.
Partner/ spouse support is especially
important.
If you hang around people who
don’t smoke you are more likely
to quit and stay quit.

Use 12 Step Skills
 This too shall pass
 Easy Does it
 Pray
 Call supports
 Talk about it
 Etc..

“First Line” medications that are FDA
approved for tobacco cessation include:
 Nicotine Replacement Therapy (NRT)
 Bupropion (Zyban) (Wellbutrin)
 Varenicline (Chantix).

 Nicotine-replacement therapy (NRT) works
by weaning the smoker off nicotine
gradually, usually over a period of weeks
or months.

NRT
 Gum
 Lozenge
 Patch
 General rule is 1 mg NRT per each Cig daily. Ex.
20 daily cigs= 20 mg patch
 Prescription NRT Inhaler and Nasal Spray

Possible Side effects of NRT
 1/3 people get patch site irritation
(discontinue if blisters)
 Nausea
 Vivid dreams and nightmares

 Some doctors recommend using two or more such as
patch and gum for cravings.
 Has been shown to be more effective than single NRT
especially for heavy smokers

Vare nic line -Chantix
 Prescribed by a doctor
 Binds to nicotine receptors
 Very effective for some people
 Some people report side effects.
 Recent FDA warnings of reports of suicidal
thoughts, aggressive and erratic behavior
possible blackouts. Currently under
evaluation.
 May worsen symptoms of mental illness.

 Prescribed by a doctor.
 Should be started a week before quitting.
 An antidepressant that works to curb
nicotine cravings by interfering with the
reward circuit in the brain.
 Most effective combined with behavioral
interventions/ social support.
 There is evidence that Bupropion
combined with nicotine patches has a
higher success rate than patches alone.

 Medication is not as effective on its own.
 Best in combination with behavioral
interventions and social support.
 Reports of effectiveness of medications vary.
 The “best” cessation technique varies from
person to person, so just keep trying different
methods and combinations until you find the one
that works.

One study comparing efficacy of varenicline (Chantix) and Bupropion
(Zyban.) This study did not look at social or behavioral supports,
NRT, or combination therapies.

 Such as Nortriptyline and Clonodine may be
prescribed for people unable to use first-line
medications because of contraindications or side
effects, or for patients for whom first-line
medications are not helpful.
 Have been shown to be effective for some
people in clinical trials; however they are not
FDA-approved for smoking cessation and may
have significant side effects. Some may have
particular contraindications for recovering
alcoholics/addicts.

Many people swear by holistic methods
such as
 Hypnosis
 Acupuncture
 Acupressure
 Guided relaxation/imagery

 Use a 12 step program.
 Talk about not smoking, cravings etc…
 Find ways to socialize without smoking.
 Hang out with non smokers.
 Avoid putting yourself in situations that
might trigger you.
 Consider NRT or medication to aid you

Quitting

Just Do It
 Recent studies have shown that
unplanned attempts to quit may be more
effective than planned attempts

Getting Ready
 Start breaking routines associated with
smoking
 Clean the house – throw out smoking stuff
 Have your car cleaned and deodorized
 Start smoking with the opposite hand
 Don’t smoke in your usual places
 Educate yourself
 Plan for dealing with cravings

 Take up yoga, tai chi, walking, jogging, sports,
dancing, gardening or any other healthy activity.
 Volunteer, do service work– it will get the focus
off tobacco and help the community as well as
you.
 Find opportunities to be with others who do not
smoke.
 Find things to do around your home – get some
of the things done that you’ve been postponing.

 Good nutrition can help deal with cravings,
ease detox, reduce mood swings and
weight gain.
 Avoid sugar, simple carbs and coffee.
 Focus on fruits, veggies and whole grains.
 Avoid foods that trigger cravings.
 Have healthy snacks on hand to help
with cravings.
 Drink lots of water to aid detox.

 Identify as someone who doesn’t use
tobacco.
 Don’t glamorize smoking.
Care about your health!

When you really crave a cigarette:
 Remember: “This too shall pass.”
 Where you are and what is going on can make
you crave a cigarette. A change of scene can
really help. Go outside, or go to a different
room. You can also try changing what you are
doing.
 Look at your plan for things to do to manage
cravings. Try them! Trying anything to beat the
urge is better than not trying.
 “Move a muscle, change a thought”

Coping with cravings
 Exercise in brief bursts
 Call a support
 Talk to someone about something that has
nothing to do with you. (Get out of
yourself)
 Think of all the important reasons you
have decided to quit.

1,000 smokers trying to quit
500
400 1st try
# Successful
300 2nd try
3rd try
200 4-6th try
100 7th try
0

 If you "slip," don't give up. Keep trying!
 If you slip and use tobacco: call your
support and talk about what you can do to
keep from using tobacco again.
 If you relapse and start using tobacco , try
to quit again soon. Set a new quit date and
get back on track.
 Don’t beat yourself up – most people
attempt to quit several times before they
are successful. (at least 5 times)

“Smoking Areas In Restaurants Are Like
Peeing Areas In Swimming Pools.”
“unknown”