Fran Lowry

December 07, 2015

HUNTINGTON BEACH, California – A substantial proportion of people who continue to smoke after they develop a smoking-related illness, such as lung cancer or emphysema, have multiple substance use disorders.

For these individuals, the standard nicotine-dependence interventions may not suffice to help them quit smoking, a new study suggests.

"We don't know why they continue to smoke, but standard treatments may not work in these individuals, so our message to physicians is simple," investigator Ajay Manhapra, MD, from the VA Connecticut Health System and Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News. "When you see a person with an illness that is caused or worsened by smoking, and they continue to smoke, be aware that a substantial proportion of them will have other addictive disorders, and this will complicate the entire treatment regimen.

Dr Ajay Manhapra

"Smoking cessation is probably going to be very difficult in that population, and the standard things like sending them home with a nicotine patch probably won't work. It is likely that a more integrative approach that incorporates substance abuse will be required," Dr Manhapra said.

He presented findings from his research in a paper presentation session here at the American Academy of Addiction Psychiatry (AAAP) 26th Annual Meeting.

Some Would Rather Die Than Switch

While he was practising as a community internist, Dr Manhapra observed patients with smoking-related illness who continued to smoke despite knowing the damage they were doing to their health.

"I saw people with emphysema who were on oxygen and yet continued to smoke. I saw people with peripheral vascular disease that would improve if they stopped, and yet they kept on smoking. I would see people with COPD who used oxygen, yet they would still smoke, and they would end up in burn units. Yet, if they stopped smoking, their breathing would get better, their walking would improve. I started to wonder why these people continued to do something that was so harmful to them."

Dr Manhapra and colleague Robert Rosenheck, MD, from Yale School of Medicine, sought to explore a possible association of substance use disorders with current smoking among people with chronic smoking-related illness.

The investigators analyzed information from the national Veterans Health Administration (VHA) administrative records for 2012.

Among the veterans who had smoking-related chronic medical illnesses, 519,918 had a diagnosis of tobacco use disorder, designated ICD-9 code 305.1, which reflected current smoking.

These veterans were then compared with the 2,691,840 veterans who were without a diagnosis of tobacco use disorder. As expected in a VHA database, the majority (96%) were male.

Current smokers were younger, had a lower body mass index, and had less annual income than the nonsmokers.

Substance use disorder was markedly higher among smokers than nonsmokers (24.89% vs 5.44%). This included alcohol use disorder (20.41% vs 4.29%) and drug use disorder (13.54% vs 2.61%).

Additionally, 20.33% of the smokers had a diagnosis of both alcohol use disorder and drug use disorder, compared with just 4.42% of nonsmokers.

The analysis also showed that current smokers were almost three times more likely than nonsmokers to have alcohol use disorder (odds ratio [OR], 2.94; 95% confidence interval [CI], 2.90 - 2.97) and were almost two times more likely to have drug use disorder (OR, 1.97; 95% CI, 1.94 - 1.99).

People with substance use disorder also were more likely to be heavy smokers and to be diagnosed with tobacco use disorder.

Individuals having more than one alcohol or drug use disorder diagnosis were four times more likely to be diagnosed with tobacco use disorder (OR, 4.09; 95% CI, 4.02 - 4.16). Individuals with one diagnosis of alcohol or drug use disorder were also more likely to be diagnosed with tobacco use disorder (OR, 3.32, 95% CI, 3.29 - 2.36).

Smoking Cessation Interventions Can Help

Medscape Medical News invited Smita Das, MD, PhD, from Stanford University School of Medicine, Stanford, California, to comment on this study.

Dr Smita Das

"The presentation highlights a known and often ignored concept, which is that people who smoke have chronic illness and that many have concurrent substance use disorders. Given the long-time behavioral and physiological correlation of tobacco use and substance use, compounded by the greatly disabling chronic medical conditions that result, it is clear that combined ATOD [alcohol, tobacco, and other drug] treatments are warranted across medical systems," Dr Das said.

"A meta-analysis by Prochaska et al found that smoking cessation interventions provided during addictions treatment were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. Tobacco remains the leading cause of preventable death in the US, accounting for more damage than alcohol and all other drugs combined. Absolutely, as today's presentation suggests, integrated treatment is needed," she said.

"What is surprising about the data is that only 16% of the sample of people with smoking-related chronic medical illness in this study smoke. This seems rather low, given what I know about smoking rates in veterans and from clinically working in the VA. Dr Manhapra does point out that tobacco use disorders are not listed in the problem list often, which accounts for the low rates presented in this paper. However, the lack of documentation points to a bigger issue about providers not assessing for and presumably not treating or giving attention to tobacco use disorders. This needs to change."

The study was funded by a research grant under the Research in Addiction Medicine Scholars Program from the National Institute of Drug Abuse. Dr Manhapra and Dr Das report no relevant financial financial relationships.

American Academy of Addiction Psychiatry (AAAP) 26th Annual Meeting. Presented December 5, 2015.

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