Q&A: Why quitting smoking should be included in substance use and mental health treatment

A: What we know is that smoking prevalence is decreasing but has stalled among people who have mental health and substance use problems. We’re trying to do targeted research and interventions on BecomeAnEX (Truth Initiative’s digital cessation platform) to understand more about subgroups of people who are finding it harder to quit. There are surprisingly few interventions that focus on multiple substance use behaviors together. That is interesting to me because we know that a lot of these things—alcohol, tobacco, substance use—go together.

A:  Take the case of alcohol. Drinking is a huge risk factor for smoking relapse and it is one of the primary triggers for smoking in general. Even if it’s benign—someone goes to a party and has a drink and thinks, “I used to love having a cigarette every time I had a beer. I’ll just have one.” The same thing happens at a holiday party when you’re on a diet. There is research that has been done on this—it’s called the abstinence violation effect. People think they will have just one cookie, then they have that cookie and think they’ve already blown their diet so they might as well have two more. The same principal applies to cigarettes.

With respect to mental health problems, some people smoke to give themselves a mood boost because nicotine is a stimulant and it’s a mood enhancer. So it may be more difficult for people who have depression to quit smoking because they may have a strong craving to smoke as a way to alleviate negative or depressed mood.

People use alcohol, tobacco or other substances together for different reasons depending on age as well. Young adults have the highest rates of substance use—alcohol, drugs and tobacco—relative to any other age group. And during that time they are experiencing a lot of life transitions that encourage experimentation and initiation. They might be going to college, joining the military, starting a job or starting a family—that’s when they are more likely to develop substance use patterns that could carry into older adulthood.

A: There is a barrier to integrating smoking cessation services in substance abuse treatment for that very reason. We looked at national data from all of the substance abuse treatment facilities in the country and examined the prevalence of them offering smoking cessation services and found that it was lower than expected. Some clinicians misperceive that patients will become destabilized if they get rid of their nicotine and this will cause a relapse. Additionally, some of the staff members themselves smoke, so it can be difficult to tell clients not to smoke if they are also smoking.

The data show that if you treat tobacco or smoking and substance use at the same time, people have not only better tobacco outcomes, but better substance use outcomes. So there is good reason to treat them together.

A: Research shows that people have better outcomes when these factors are addressed together. We know that people who have substance use problems and mental health issues have worse smoking cessation treatment outcomes, have more severe nicotine dependence, and are more likely to relapse, so why wouldn’t you want to work on these together?