I applaud the growing trend toward decreasing the prevalence of smoking among the general public. But as an addiction psychiatrist, I have come to disagree with what I consider an extremist approach toward patients with addiction to alcohol and illicit drugs who smoke cigarettes.
Allow me to elaborate.
Some substance abuse treatment facilities have implemented policies that seemingly give the same weight to cigarette smoking cessation as they do to stopping alcohol and illicit drug abuse. This is problematic, as it may well be a violation of the treatment philosophy of 12-step recovery programs. The published statements of Alcoholics Anonymous (AA) support my contention.
Dr. Joseph Markowitz
Patients who attend AA meetings and get sidetracked with topics other than drinking are reminded that the purpose of the organization is to help recovering alcoholics achieve abstinence from alcohol (Cochrane Database Syst. Rev. 2006 July 19;CD005032). Indeed, the only requirement for AA membership is "an honest desire to stop drinking," its literature says. The group’s "primary purpose is to stay sober and help other alcoholics to achieve sobriety" (Alcoholics Anonymous, 4th ed. [New York: AA World Services, 2001]). Therefore, it’s fair to conclude that AA allows people who continue to smoke cigarettes to participate in its program. Analogously, the role of Narcotics Anonymous is to help people stop using drugs (such as cannabis, cocaine, and opiates), and nicotine has not traditionally been labeled as a "street" or "illicit" drug.
I think our role as addiction physicians is to address problems likely to kill or harm the patient immediately. Addiction to alcohol typically leads to more and more immediate problems than does addiction to nicotine. Cocaine use can lead to strokes or heart attacks, and to societal problems such as shootings or stabbings in drug deals gone badly. Opiate use, particularly intravenous, can lead to the same sort of medical and societal problems. A patient’s smoking is not likely to lead to DUIs, violent crime, job loss, or other immediate problems.
Don’t get me wrong. I certainly understand that cigarette smoking is a very serious health hazard that can lead to "lung and other cancers, cardiac and pulmonary disease, perinatal problems, cough, shortness of breath, and accelerated skin aging," according to the DSM-5. More than 160,000 Americans died last year of lung cancer alone. I get why the American Medical Association has issued guidelines on the responsibilities of physicians for tobacco cessation. These guidelines encourage physicians to ask all patients about smoking at every visit. In addition, I know what the evidence says about smoking cessation and abstinence from other substances. However, in order for us to have a shot at achieving treatment success with patients who are addicted to illicit substances and alcohol, we must home in on those issues. When one of the institutions with which I was affiliated made clear to patients that 1) smoking was banned all over the grounds, 2) cigarettes would be considered contraband, and 3) discharge may well be the penalty for being caught smoking, the patients all too frequently said they did not want to go to that facility. Many of the patients subsequently completely lost interest in treatment.
In my practice, I use motivational interviewing techniques and traditional approaches to try to get patients to stop smoking. However, I don’t "knock people over the head" with this and would never do anything that would be an added barrier to quitting drinking or drug use. Given the limited time we have in formal drug and alcohol treatment programs, we need to stay focused on the primary substance abuse issue that brought the patient to clinical attention. Are we going to tell alcoholics or cocaine addicts that they cannot get treatment unless they agree to quit smoking also? Are we going to kick people out of treatment for smoking a cigarette – even outside the building? Are we going to label someone who has stopped drinking or using drugs, has a job, is doing well raising a family, is not in legal trouble, and is paying taxes as a "partial success" or a "failure" if they continue to smoke? I certainly hope not.
Let me reiterate: I take smoking seriously, and I want patients to quit. On the other hand, I do not support making smoking cessation a condition for treatment of a drug or alcohol abuse problem. I do not support throwing patients out of treatment if they are caught having a cigarette or using the precious time we have during treatment to focus too much on smoking. Too often, draconian measures against cigarette smoking become a distraction to a patient who already is likely experiencing withdrawal symptoms and distress while attempting to stop using illicit drugs and alcohol. Very often patients also are dealing with a myriad of other health and social problems.