Tobacco, cocaine, and heroin: Craving and use during daily life
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.
References (43)
- et al.
Smoking cessation during substance abuse treatment: What you need to know
Journal of Substance Abuse Treatment
(2009) - et al.
Nicotine and caffeine use in cocaine-dependent individuals
Journal of Substance Abuse
(1993) - et al.
Treating cigarette smoking in drug-abusing clients
Journal of Substance Abuse Treatment
(1995) - et al.
Smoking habits and attitudes in a methadone maintenance treatment population
Drug and Alcohol Dependence
(1997) - et al.
Optimizing smoking cessation outcomes among the methadone maintained
Journal of Substance Abuse Treatment
(2002) - et al.
Concurrent versus delayed smoking cessation treatment for persons in early alcohol recovery: A pilot study
Journal Of Substance Abuse Treatment
(2001) - et al.
Naltrexone alteration of acute smoking response in nicotine-dependent subjects
Pharmacology, Biochemistry and Behavior
(2000) - et al.
Nicotine alters some of cocaine's subjective effects in the absence of physiological or pharmacokinetic changes
Pharmacology, Biochemistry & Behavior
(2001) - et al.
The nicotinic antagonist mecamylamine preferentially inhibits cocaine vs. food self-administration in rats
Physiology & Behavior
(2000) - et al.
A nicotine antagonist, mecamylamine, reduces cue-induced cocaine craving in cocaine-dependent subjects
Neuropsychopharmacology
(1999)
An acute dose of nicotine enhances cue-induced cocaine craving
Drug and Alcohol Dependence
A comparison of cocaine-dependent cigarette smokers and non-smokers on demographic, drug use and other characteristics
Drug and Alcohol Dependence
Prediction of lapse from associations between smoking and situational antecedents assessed by ecological momentary assessment
Drug and Alcohol Dependence
Contingency management for tobacco smoking in methadone-maintained opiate addicts
Addictive Behaviors
Effects of nicotine on methadone self-administration in humans
Drug and Alcohol Dependence
Cigarette smoking among adults—United States, 2007
Morbidity and Mortality Weekly Report
Effects of methadone on human cigarette smoking and subjective ratings
Journal of Pharmacology and Experimental Therapeutics
Opiate antagonists reduce cocaine but not nicotine self-administration
Psychopharmacology
Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-up
Psychology of Addictive Behaviors
Real-time electronic diary reports of cue exposure and mood in the hours before cocaine and heroin craving and use
Archives of General Psychiatry
Associations between tobacco smoking and illicit drug use among methadone-maintained opiate-dependent individuals
Experimental and Clinical Psychopharmacology
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