Elsevier

Addictive Behaviors

Volume 35, Issue 4, April 2010, Pages 318-324
Addictive Behaviors

Tobacco, cocaine, and heroin: Craving and use during daily life

https://doi.org/10.1016/j.addbeh.2009.11.003Get rights and content

Abstract

Background

Relationships among tobacco smoking, tobacco craving, and other drug use and craving may have treatment implications in polydrug-dependent individuals.

Methods

We conducted the first ecological momentary assessment (EMA) study to investigate how smoking is related to other drug use and craving during daily life. For up to 20 weeks, 106 methadone-maintained outpatients carried PalmPilots (PDAs). They reported their craving, mood, behaviors, environment, and cigarette-smoking status in 2 to 5 random-prompt entries/day and initiated PDA entries when they used cocaine or heroin or had a discrete episode of craving for cocaine or heroin.

Results

Smoking frequency increased linearly with random-prompt ratings of tobacco craving, cocaine craving, and craving for both cocaine and heroin. Smoking frequency was greater during discrete episodes of cocaine use and craving than during random-prompt reports of low craving for cocaine. This pattern was also significant for dual cocaine and heroin use and craving. Smoking and tobacco craving were each considerably reduced during periods of urine-verified abstinence from cocaine, and there was a (nonsignificant) tendency for morning smoking to be especially reduced during those periods.

Conclusions

This EMA study confirms that smoking and tobacco craving are strongly associated with the use of and craving for cocaine and heroin. Together with prior findings, our data suggest that tobacco and cocaine may each increase craving for (and likelihood of continued use of) themselves and each other. Treatment for tobacco dependence should probably be offered concurrently with (rather than only after) initiation of treatment for other substance-use disorders.

Introduction

High rates of cigarette smoking are common among polydrug users, especially those with cocaine and opiate dependence. Smoking prevalence is approximately 80–95% among methadone-maintained individuals (Clemmey, Brooner, Chutuape, Kidorf & Stitzer, 1997), whereas it is 20% among adults in the general population (Centers for Disease Control and Prevention, 2008). Among cocaine-dependent individuals, cigarette smokers report using cocaine at an earlier age (Budney, Higgins, Hughes & Bickel, 1993), more frequently (Budney et al., 1993, Roll et al., 1996), and in greater amounts (Roll et al., 1996) than nonsmokers. Cigarette smoking among substance abusers causes substantial morbidity and mortality (Hurt et al., 1996); it might even be fairly concluded that smoking is “more deadly to substance-abuse patients than their primary presenting substance of abuse” (Baca & Yahne, 2009).

Although there is a consensus that tobacco dependence should be addressed in substance-abuse treatment, there is no firm agreement on the best timing. Traditionally, methadone programs have not treated tobacco dependence (Guydish, Passalacqua, Tajima & Manser, 2007). Some clinicians have argued that a smoking-cessation attempt might interfere with a concurrent attempt to decrease other drug use (Campbell et al., 1995, Weinberger et al., 2008, Weinberger and Sofuoglu, 2009). Most studies, however, have shown that tobacco-dependence treatment offered concurrently with other substance-abuse treatment does not increase use of other drugs and may even improve outcome (Baca and Yahne, 2009, Prochaska et al., 2004). There is also evidence that illicit drug use makes smoking cessation more difficult (Frosch et al., 2002, Stapleton et al., 2009). Quit rates for tobacco smoking among substance abusers are low, even with treatment (Campbell et al., 1995, Kalman et al., 2001). A meta-analysis suggested that tobacco-dependence treatment during other addiction treatment is more effective in the short term than in the long term, but may nonetheless increase long-term abstinence from other substances (Prochaska et al., 2004).

Patients and clinicians might be better equipped to make decisions about the timing of smoking-cessation efforts if they had more systematic information about how smoking interacts with other drug use and craving during daily life. Although a few recent studies have assessed the effects of tobacco-dependence treatment among methadone patients (Frosch et al., 2000, Shoptaw et al., 1996), no studies have closely examined how ongoing smoking relates to other drug use and craving in the daily lives of methadone patients. In smokers who do not report other substance-use problems, daily patterns of smoking and tobacco craving have been extensively characterized with ecological momentary assessment (EMA) (Shiffman, 2005, Shiffman et al., 2007, Shiffman and Paty, 2006, Shiffman et al., 2008). In this study, we used EMA to examine how cigarette smoking and craving are related to cocaine and heroin use and craving in the daily lives of methadone-maintained outpatients.

Section snippets

Participants and setting

Participants were methadone-maintained cocaine- and heroin-using outpatients at a treatment-research clinic in Baltimore, MD. The NIDA Institutional Review Board approved the study, and participants gave written informed consent before being enrolled. We have reported other results from the same study in a prior publication (Epstein et al., 2009); methodological details are given there and summarized here.

Inclusion criteria were: (1) age between 18 and 65, (2) evidence of physical dependence on

Results

Included in the data were 25,347 random-prompt entries collected from the 106 participants who smoked; participants reported smoking in 8173 (32%) of those entries. There were 2413 event-contingent entries (entries at which participants reported episodes of cocaine or heroin use or craving); participants reported tobacco smoking in 1260 (52%) of those entries. However, there were far fewer reports of heroin use (n = 60) than of cocaine use (n = 665), cocaine craving (n = 597), heroin craving (n = 257),

Summary of findings

This is the first study to investigate how cigarette smoking relates to other drug use and craving in real time as polydrug-dependent participants engage in their daily activities. As in the studies cited in the Introduction, smoking was very common in our sample. Of the 114 participants who enrolled and provided EMA data, 106 (93%) were smokers. Smoking was reported in approximately one third of all random prompts and on more than 50% of occasions on which cocaine use was reported.

Our study

Role of Funding Sources

This work was funded by the NIDA Intramural Research Program, which had no further role in the study design, analysis/interpretation of data, the writing of the report, or the decision to publish.

Contributors

Drs. Epstein, Preston, and Schmittner designed the study and wrote the protocol and oversaw its implementation. Dr. Heishman subsequently suggested collecting data about tobacco smoking as part of the protocol; in preparing this manuscript, he and Ms. Marrone managed the literature searches and wrote the first draft of Introduction and Discussion. Dr. Epstein conducted the data analyses and drafted the Methods and Results sections of the manuscript. All authors contributed to and have approved

Conflict of Interest

No conflict declared.

Acknowledgement

This work was funded by the NIDA Intramural Research Program.

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