treating tobacco dependence in patients with other addictions richard d. hurt, m.d. professor of...

Treating Tobacco Dependence in Treating Tobacco Dependence in Patients with Other AddictionsPatients with Other Addictions

Richard D. Hurt, M.D.Richard D. Hurt, M.D.

Professor of Medicine, Mayo Clinic College of Professor of Medicine, Mayo Clinic College of MedicineMedicine

Director, Nicotine Dependence CenterDirector, Nicotine Dependence Centerhttp://ndc.mayo.eduhttp://ndc.mayo.edu

Smoking and Mental Illness Smoking and Mental Illness

• 22% of people who have never been 22% of people who have never been diagnosed with a mental illness currently diagnosed with a mental illness currently smoke.smoke.

• 34.8% of people who have had been 34.8% of people who have had been diagnosed with a mental illness sometime diagnosed with a mental illness sometime in their life currently smoke.in their life currently smoke.

• 41% of people who have been diagnosed 41% of people who have been diagnosed with a mental illness In the past month with a mental illness In the past month currently smokecurrently smoke

• 44% of all cigarettes smoked are by people 44% of all cigarettes smoked are by people with a ‘past-month’ mental health with a ‘past-month’ mental health diagnosis.diagnosis.

Lasser et. Al. 2000Lasser et. Al. 2000

Nicotine Dependence and Psychiatric DisordersNicotine Dependence and Psychiatric DisordersU.S. AdultsU.S. Adults

• National Epidemiologic Survey on Alcohol and National Epidemiologic Survey on Alcohol and Related ConditionsRelated Conditions

• Face-to-face interviews (N=43,093) to Face-to-face interviews (N=43,093) to determine co-occurrence of DSM-IV nicotine determine co-occurrence of DSM-IV nicotine dependence and Axis I & II psychiatric dependence and Axis I & II psychiatric disordersdisorders

• NIAAA Alcohol Use Disorder and Associated NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule – DSM-IVDisabilities Interview Schedule – DSM-IV

• Current cigarette use = any use in past year. Current cigarette use = any use in past year. Characterized on days smoked and cigarettes Characterized on days smoked and cigarettes usually smokedusually smoked

Grant BF. Arch Gen Psychiatry 61:1107, 2004Grant BF. Arch Gen Psychiatry 61:1107, 2004

Nicotine Dependence and Psychiatric DisordersNicotine Dependence and Psychiatric DisordersU.S. AdultsU.S. Adults

TotalTotal MalesMales FemalesFemales

Current smokersCurrent smokers 24.9%24.9%

Nicotine dependenceNicotine dependence 13%13% 14%14% 11%11%

Alcohol abuseAlcohol abuse 5%5% 7%7% 3%3%

Alcohol dependenceAlcohol dependence 3%3% 5%5% 2%2%


Prevalence of Psychiatric Disorders Among Prevalence of Psychiatric Disorders Among Respondents with Nicotine DependenceRespondents with Nicotine Dependence

Alcohol use disorderAlcohol use disorder 23%23%

Alcohol abuseAlcohol abuse 9%9%

Alcohol dependenceAlcohol dependence 13%13%

Major depressionMajor depression 17%17%

Anxiety disorderAnxiety disorder 22%22%

Personality disorderPersonality disorder 32%32%


Prevalence of Nicotine Dependence Prevalence of Nicotine Dependence Among Psychiatric DisordersAmong Psychiatric Disorders

Alcohol use disorderAlcohol use disorder 34%34%

Alcohol abuseAlcohol abuse 25%25%

Alcohol dependenceAlcohol dependence 45%45%

Drug use disorderDrug use disorder 52%52%

Drug abuseDrug abuse 45%45%

Drug dependenceDrug dependence 69%69%

Major depressionMajor depression 30%30%

Anxiety disorderAnxiety disorder 25%25%

Personality disorderPersonality disorder 27%27%


Alcoholism and SmokingAlcoholism and SmokingBackgroundBackground

• Regular smoking usually precedes Regular smoking usually precedes development of alcoholismdevelopment of alcoholism

• 2-3x 2-3x in prevalence of smoking among in prevalence of smoking among substance abuserssubstance abusers

• 10x 10x in prevalence of alcoholism in prevalence of alcoholism among heavy smokers vs. nonsmokersamong heavy smokers vs. nonsmokers

• Smoking alcoholics constitute 26% of Smoking alcoholics constitute 26% of all smokersall smokers

Alcoholism and Tobacco DependenceAlcoholism and Tobacco DependenceBill Wilson, AA Co-founderBill Wilson, AA Co-founder

““A heavy, sloppy smoker all his life, he A heavy, sloppy smoker all his life, he developed emphysema in the 1960s. It developed emphysema in the 1960s. It killed him. He gave his last speech to killed him. He gave his last speech to the International AA Convention in the International AA Convention in Miami in 1970, lifted to the platform in a Miami in 1970, lifted to the platform in a wheelchair, gasping for breath and wheelchair, gasping for breath and sucking oxygen from the tank that was sucking oxygen from the tank that was always with him.”always with him.”

Robertson: Inside Alcoholics AnonymousRobertson: Inside Alcoholics Anonymous

Mortality Following Inpatient Mortality Following Inpatient Addictions TreatmentAddictions Treatment

Study DesignStudy Design

• Olmsted County patients admitted for Olmsted County patients admitted for inpatient addictions treatment 1972-1983inpatient addictions treatment 1972-1983

• Follow-up through 1994 – Rochester Follow-up through 1994 – Rochester Epidemiology ProjectEpidemiology Project

• Vital status and death certificatesVital status and death certificates

• CDC classification of alcohol or CDC classification of alcohol or tobacco-related cause of deathtobacco-related cause of death

Hurt RD, et al. JAMA 275:1097, 1996Hurt RD, et al. JAMA 275:1097, 1996


Patient DemographicsPatient Demographics

• n=845 (65% men, 35% women)n=845 (65% men, 35% women)

• Mean age at admission – 41.4 yearsMean age at admission – 41.4 years

• 78% alcohol only, 18% alcohol and 78% alcohol only, 18% alcohol and other drugsother drugs

• 75% current and 8% former smokers75% current and 8% former smokers

• Length of follow-up/patient – 10.5Length of follow-up/patient – 10.55.6 5.6 years (8913 pt/yrs)years (8913 pt/yrs)


Hurt RD, et al. JAMA 275:1097, 1996


Tobacco or Alcohol Cause of DeathTobacco or Alcohol Cause of Death

PercentPercent ObservedObserved ExpectedExpected RRRR

AlcoholAlcohol 3434 7373 1818 4.14.1

TobaccoTobacco 5151 109109 5353 2.02.0



ConclusionsConclusions

• High risk for premature mortalityHigh risk for premature mortality

• Tobacco-related diseases leading Tobacco-related diseases leading cause of deathcause of death

• Treating tobacco dependence is Treating tobacco dependence is imperative in this high risk groupimperative in this high risk group


Treating Alcohol and Tobacco Dependence Treating Alcohol and Tobacco Dependence SimultaneouslySimultaneously

DesignDesign

• Prospective nonrandomized controlled Prospective nonrandomized controlled trial with 1 year abstinence outcomestrial with 1 year abstinence outcomes

• Inpatient addictions treatment unitInpatient addictions treatment unit

• Control group (n=50) – usual careControl group (n=50) – usual care

• Intervention group (n=51)Intervention group (n=51)• ConsultationConsultation• Group sessions (5)Group sessions (5)• Education sessions (5)Education sessions (5)• Telephone follow-upTelephone follow-up

Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994Hurt RD, et al. Alcohol Clin Exp Res 18:867, 1994


Substance Use HistorySubstance Use History

InterventionIntervention

N=51N=51

ControlControl

N=50N=50

PP

Alcohol only (%)Alcohol only (%) 74.574.5 54.054.0 0.0310.031

Smoking rate Smoking rate (CPD)(CPD) 25.025.08.78.7 21.321.310.710.7 0.0520.052

Smoking onset Smoking onset (age)(age) 14.614.63.73.7 16.616.65.65.6 NSNS

Year smokedYear smoked 26.626.612.412.4 19.919.910.810.8 0.0120.012



Abstinence OutcomesAbstinence Outcomes

InterventionIntervention

N=51N=51

ControlControl

N=50N=50

PP

No alcohol/drugs No alcohol/drugs at 1 yearat 1 year 68.668.6 6666 NSNS

Not smoking at Not smoking at dismissaldismissal 21.621.6 10.010.0 NSNS

Not smoking at Not smoking at 1 year1 year 11.811.8 00 0.0270.027




• 11.8% tobacco abstinence rate 11.8% tobacco abstinence rate acceptable but can be improvedacceptable but can be improved

• Study run in less than optimal Study run in less than optimal environmentenvironment

• Perception that it is hard is realPerception that it is hard is real

• No apparent negative effect on No apparent negative effect on abstinence from alcohol or other drugsabstinence from alcohol or other drugs

• Unit became tobacco-free after studyUnit became tobacco-free after study


Nicotine Patch Therapy in Recovering Nicotine Patch Therapy in Recovering Alcoholic SmokersAlcoholic Smokers

Baseline CharacteristicsBaseline Characteristics

Recovering Recovering Alcoholics Alcoholics

(n=43)(n=43)

Nonalcoholic Nonalcoholic (n=314)(n=314) PP value value

CPDCPD 34.134.19.69.6 28.028.010.410.4 <0.001<0.001

FTQFTQ 9.19.13.23.2 8.18.13.33.3 0.0220.022

Baseline Baseline nicotine (ng/mL)nicotine (ng/mL) 22.822.810.710.7 18.918.912.112.1 0.0070.007

Baseline Baseline cotinine (ng/mL)cotinine (ng/mL)

305.5305.5126.126.77

261.28 261.28 118.8118.8 0.0490.049

Hurt RD, et al. Addiction 90:1541, 1995Hurt RD, et al. Addiction 90:1541, 1995

Nicotine Patch Therapy in Recovering Nicotine Patch Therapy in Recovering Alcoholic SmokersAlcoholic Smokers


• More nicotine dependent than More nicotine dependent than nonalcoholicsnonalcoholics

• Can achieve short-term tobacco abstinence Can achieve short-term tobacco abstinence with nicotine patch therapywith nicotine patch therapy

• May require more intensive intervention:May require more intensive intervention:• Dose matchingDose matching• Longer treatmentLonger treatment behavioral interventionbehavioral intervention relapse preventionrelapse prevention

Hurt RD, et al. Addiction 90:1541, 1995Hurt RD, et al. Addiction 90:1541, 1995

Nicotine Patch Therapy in Alcoholic SmokersNicotine Patch Therapy in Alcoholic SmokersDemographicsDemographics

Nonalcoholic Nonalcoholic (n=281)(n=281)

Recovering Recovering (n=53)(n=53)

Active Active (n=48)(n=48) PP

AgeAge 45.245.21.31.3 43.843.810.8 10.8 42.842.811.11.22 NSNS

% female% female 6161 4242 3737 0.0010.001

Smoking Smoking rate (CPD)rate (CPD) 26.426.49.19.1 30.630.612.112.1 29.829.811.11.

33 0.0040.004

FTQFTQ 6.96.91.81.8 8.48.41.71.7 7.87.81.91.9 <0.001<0.001

Hays JT, et al. Ann Behav Med 21:244, 1999Hays JT, et al. Ann Behav Med 21:244, 1999

Nicotine Patch Therapy in Alcoholic SmokersNicotine Patch Therapy in Alcoholic SmokersTobacco Abstinence RatesTobacco Abstinence Rates

62.6

58

26.7

54.2

41.7

25

43.4

34

15.1

0

10

20

30

40

50

60

70

week 4 week 8 week 26

% n

ot

sm

ok

ing

no alcohol problem (n=281)

active alcohol problem (n=48)

past alcohol problem (n=53)

Hays JT, et al. Ann Behav Med 21:244, 1999Hays JT, et al. Ann Behav Med 21:244, 1999

High Dose Nicotine Patch Therapy High Dose Nicotine Patch Therapy in Heavy Smokersin Heavy Smokers

MethodsMethods

• Post hoc analysis of 1039 heavy smokers (Post hoc analysis of 1039 heavy smokers (30 30 cpd)cpd)

• Screened for current alcohol problem with short Screened for current alcohol problem with short alcohol dependence data questionnairealcohol dependence data questionnaire

• Smokers with alcohol problems in past year were Smokers with alcohol problems in past year were excludedexcluded

• Nicotine patch dose – placebo, 21 mg, 35 mg, or 42 Nicotine patch dose – placebo, 21 mg, 35 mg, or 42 mgmg

• Higher nicotine patch doses were “slightly more Higher nicotine patch doses were “slightly more efficacious”efficacious”

Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003Hughes, JR, et al. Drug Alcohol Depend 71:269, 2003


Past HistoryPast History

No problems No problems (n=879)(n=879)

Alcohol Problems Alcohol Problems (n=160)(n=160)

AgeAge 4444 4242

% men% men 4747 6666

Cigs/dayCigs/day 3838 3838

CO (ppm)CO (ppm) 3333 3434

FTQFTQ 7.97.9 8.38.3

Years smokedYears smoked 2626 2626


• In heavy smokers with or without past In heavy smokers with or without past history of alcohol problems, no history of alcohol problems, no difference in:difference in:• time to lapsetime to lapse• prolonged tobacco abstinenceprolonged tobacco abstinence

• Thus, past history of alcohol problems Thus, past history of alcohol problems does not predict a worse outcomedoes not predict a worse outcome




Bupropion for Smokers with past History of Bupropion for Smokers with past History of Alcoholism or DepressionAlcoholism or Depression

ResultsResults

• Neither PHMDD nor alcoholism Neither PHMDD nor alcoholism associated with abstinence at EOT associated with abstinence at EOT (p=0.93) or 1 year (p=0.23)(p=0.93) or 1 year (p=0.23)

• Dose response effect for bupropion Dose response effect for bupropion at EOT (p<0.001) and 1 year (p=0.02)at EOT (p<0.001) and 1 year (p=0.02)

Hayford KE, et al. Br J Psychiatry 174:173, 1999Hayford KE, et al. Br J Psychiatry 174:173, 1999

Pharmacologic Relapse Prevention for Pharmacologic Relapse Prevention for Recovering Alcoholic SmokersRecovering Alcoholic Smokers

Weeks 1-8Weeks 1-8

Open label tailored Open label tailored nicotine patch therapynicotine patch therapy

(n=195)(n=195)

Bupropion 300 mg/dBupropion 300 mg/d(n=56)(n=56)

PlaceboPlacebo(n=54)(n=54)

Follow-upFollow-up

Week Week 5252

Week Week 7676

R01 AA-11219R01 AA-11219

Nicotine Patch Dose Based on Nicotine Patch Dose Based on Serum CotinineSerum Cotinine

Baseline Serum Baseline Serum CotinineCotinine

Initial Nicotine Patch Initial Nicotine Patch Dose, mg/dDose, mg/d

200200 2222

201-300201-300 3333

> 301> 301 4444

Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.Hurt RD, et al. J Stud Alcohol 66:506-516, 2005.

Tailored Nicotine Patch Therapy for Tailored Nicotine Patch Therapy for Recovering Alcoholic SmokersRecovering Alcoholic Smokers

Serum CotinineSerum Cotinine

Week 2Week 2

Patch dosePatch dose nn BaselineBaseline nn Abstinent Abstinent subjectssubjects nn Smoking Smoking

subjectssubjects

22 mg22 mg

CotinineCotinine 2525 165165 1818 125125 77 178178

% of baseline% of baseline 77%77% 113%113%

33 mg33 mg



44 mg44 mg




Smoking Abstinence RatesSmoking Abstinence Rates

0102030405060708090

100

1 2 3 4 5 6 7 8

Visit Number

No

t S

mo

kin

g,

%

75/19575/195

96/19596/195 94/19594/195 94/19594/195 95/19595/195 93/19593/195 94/19594/195 100/195100/195


Tailored Nicotine Patch Therapy forTailored Nicotine Patch Therapy forRecovering Alcoholic SmokersRecovering Alcoholic Smokers

Smoking AbstinenceSmoking Abstinence

0

20

40

60

80

100

1 2 3 4 5 6 7 8

CP1120196B-1

Ab

stin

ent

(%)

Visit number

7-day point prevalenceContinuous

Hurt RD, et al. J Stud on Alcohol, 66:506, 2005Hurt RD, et al. J Stud on Alcohol, 66:506, 2005



• Excellent 8 week smoking Excellent 8 week smoking abstinence rate (51%) with tailored abstinence rate (51%) with tailored nicotine patch therapynicotine patch therapy

• Dosing algorithm worksDosing algorithm works

• No evidence of nicotine toxicityNo evidence of nicotine toxicity

• Very low rate of relapse to drinkingVery low rate of relapse to drinking


Nicotine Patch Therapy in AlcoholicsNicotine Patch Therapy in Alcoholics

• Efficacy of 21 or 42 mg x 4 wk (then taper) Efficacy of 21 or 42 mg x 4 wk (then taper) nicotine patch doses in heavy smokers nicotine patch doses in heavy smokers (N=130) with PH alcoholism(N=130) with PH alcoholism

• FTND score 7.7, mean smoking rate 31.5 cpdFTND score 7.7, mean smoking rate 31.5 cpd

• Median alcohol abstinence 4 months (69% Median alcohol abstinence 4 months (69% receiving alcoholism treatment at the time of receiving alcoholism treatment at the time of enrollment)enrollment)

• Longer alcohol abstinence predicted better Longer alcohol abstinence predicted better smoking abstinence outcomesmoking abstinence outcome

Kalman D, et al. Psychol Addict Behav 18:78-82, 2004Kalman D, et al. Psychol Addict Behav 18:78-82, 2004

Nicotine Patch Therapy in AlcoholicsNicotine Patch Therapy in Alcoholics

Smoking Abstinence RatesSmoking Abstinence Rates

Initial Nicotine Initial Nicotine Patch DosePatch Dose Wk 1Wk 1 Wk 4Wk 4 Wk 12Wk 12

21 mg/d21 mg/d 35.4%35.4% 30.7%30.7% 20.0%20.0%

42 mg/d42 mg/d 30.8%30.8% 20.0%20.0% 9.2%9.2%

Kalman D, et al. Psychol Addict Behav 18:78-82, 2004Kalman D, et al. Psychol Addict Behav 18:78-82, 2004

Treating Alcohol and Tobacco DependenceTreating Alcohol and Tobacco DependenceRRationale to Initiate Treatment ationale to Initiate Treatment

During Treatment of other DependenciesDuring Treatment of other Dependencies

• Serious cause of morbidity/mortalitySerious cause of morbidity/mortality

• Closely related behaviorsClosely related behaviors

• Eliminates a cue to drinkEliminates a cue to drink

• Common messageCommon message

• Apply same treatment philosophyApply same treatment philosophy

• Protected milieu to initiate an attemptProtected milieu to initiate an attempt

• Many patients in CD programs express Many patients in CD programs express interest in stopping tobacco (46-70%)interest in stopping tobacco (46-70%)

Treating Tobacco Dependence in Treating Tobacco Dependence in Alcoholics in Treatment or RecoveryAlcoholics in Treatment or Recovery

• Meta-analysis of 19 randomized controlled Meta-analysis of 19 randomized controlled trialstrials

• Post-treatment intervention effects (but not Post-treatment intervention effects (but not long-term) were significant and comparable long-term) were significant and comparable for patients in addictions treatment or for patients in addictions treatment or recoveryrecovery

• Tobacco dependence interventions provided Tobacco dependence interventions provided duringduring addictions treatment addictions treatment (25%) long- (25%) long-term alcohol and/or drug abstinenceterm alcohol and/or drug abstinence

Prochaska JJ, et al. J Consult Clin Psychol 72:1144-1156, 2004Prochaska JJ, et al. J Consult Clin Psychol 72:1144-1156, 2004

Timing of Alcohol and Smoking Timing of Alcohol and Smoking Cessation (TASC)Cessation (TASC)

• Smokers in treatment for alcohol Smokers in treatment for alcohol dependence willing to consider stopping dependence willing to consider stopping smokingsmoking

• Randomized to concurrent treatment or Randomized to concurrent treatment or delayed treatment 6 months after alcohol delayed treatment 6 months after alcohol dependence treatmentdependence treatment

• N=499, mean age 39.2, mean CPD 25.5, N=499, mean age 39.2, mean CPD 25.5, FTND 6.0, 47% previously used NRT or FTND 6.0, 47% previously used NRT or bupropionbupropion

Joseph AM. J Addict Dis 22:87-107, 2003Joseph AM. J Addict Dis 22:87-107, 2003

Timing of Alcohol and Smoking Timing of Alcohol and Smoking Cessation (TASC)Cessation (TASC)Smoking AbstinenceSmoking Abstinence

ITTITT

Concurrent Concurrent (N=251)(N=251)

Delayed Delayed (N=248)(N=248) PP

7 day PP smoking 7 day PP smoking abstinenceabstinence

3 months3 months 15.5%15.5% 4.4%4.4% <0.0001<0.0001

6 months6 months 10.8%10.8% 5.2%5.2% 0.20.2

12 months12 months 12.8%12.8% 10.1%10.1% NSNS

18 months18 months 12.4%12.4% 13.7%13.7% NSNS

Joseph AM. J Stud Alcohol 65:681, 2004Joseph AM. J Stud Alcohol 65:681, 2004

Timing of Alcohol and Smoking Timing of Alcohol and Smoking Cessation (TASC)Cessation (TASC)Alcohol AbstinenceAlcohol Abstinence

ITTITT

Concurrent Concurrent (N=251)(N=251)

Delayed Delayed (N=248)(N=248) PP

30 day alcohol abstinence30 day alcohol abstinence

6 months6 months 51%51% 64%64% 0.0040.004

12 months12 months 46%46% 53%53% 0.110.11

18 months18 months 48%48% 60%60% 0.010.01

6 month alcohol abstinence6 month alcohol abstinence

6 months6 months 41%41% 56%56% 0.0010.001

12 months12 months 33%33% 42%42% 0.060.06

18 months18 months 41%41% 48%48% 0.140.14

Joseph AM. J Stud Alcohol 65:681, 2004Joseph AM. J Stud Alcohol 65:681, 2004

Does Smoking Abstinence Threaten Does Smoking Abstinence Threaten Sobriety?Sobriety?

• 10% of recovering 10% of recovering alcoholics state it alcoholics state it doesdoes

• 16% report 16% report increased cravingincreased craving

• 18% relapse to 18% relapse to alcohol/drug use alcohol/drug use during tobacco during tobacco abstinenceabstinence

• 90% state it 90% state it DOES NOT DOES NOT threaten sobrietythreaten sobriety

• 84% report NO 84% report NO increase in cravingincrease in craving

• 82% DO NOT 82% DO NOT relapse to relapse to alcohol/drug use alcohol/drug use during tobacco during tobacco abstinence abstinence

Adapted from John Hughes, 2004

Concurrent vs Delayed Treatment for Concurrent vs Delayed Treatment for SmokingSmoking

KalmanKalmanN=36N=36

Delayed less likely to Delayed less likely to enter smoking txenter smoking tx

No difference in No difference in smoking outcomessmoking outcomes

Delayed had worse Delayed had worse alcohol outcomes alcohol outcomes (p=.07)(p=.07)

JosephJosephN=499N=499

Delayed less likely to Delayed less likely to enter smoking txenter smoking tx

No difference in No difference in smoking outcomessmoking outcomes

Concurrent had worse Concurrent had worse alcohol outcomes alcohol outcomes (p <.01)(p <.01)

Kalman D. J Subst Abuse Treat. 2001;20:233Joseph AM. J Stud Alcohol. 2004;65:681

Unanswered QuestionsUnanswered Questions

• Adequacy of brief treatments? Adequacy of brief treatments?

• Concurrent Concurrent vs.vs. delayed treatment? delayed treatment?

• Integrating 12 step and behavioral therapies?Integrating 12 step and behavioral therapies?

• Interventions for peer resistance?Interventions for peer resistance?

• Prophylactic treatment to prevent alcohol Prophylactic treatment to prevent alcohol remission?remission?

BUT . . .BUT . . .

Postponing treatment means potentially neverPostponing treatment means potentially never

Treating Tobacco Dependence in Treating Tobacco Dependence in Recovering AlcoholicsRecovering Alcoholics

• Keep tobacco use on the problem listKeep tobacco use on the problem list

• Motivate every few months using Motivate every few months using personal risks and discussing personal risks and discussing barriersbarriers

• Utilize past success strategiesUtilize past success strategies

• Associate with non-tobacco using Associate with non-tobacco using friendsfriends

• Consider an ex-tobacco user as a Consider an ex-tobacco user as a “sponsor”“sponsor”

Treating Tobacco Dependence in Treating Tobacco Dependence in Recovering AlcoholicsRecovering Alcoholics

• Recommend proven therapiesRecommend proven therapies• NRTNRT• BupropionBupropion• VareniclineVarenicline• Behavior TherapyBehavior Therapy• Social SupportSocial Support

• Monitor frequently for relapseMonitor frequently for relapse

• Let patient decide the timingLet patient decide the timing

treating tobacco dependence in patients with other addictions richard d. hurt, m.d. professor of...

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