Co-occurring disorder-related issue briefs

Co-Occurring Disorder-Related Quick Facts:

Nicotine, a component of tobacco, is the primary reason that tobacco is addictive,
although cigarette smoke contains many other dangerous chemicals, including tar, carbon
monoxide, acetaldehyde, nitrosamines, and more.1
In 1988, the Surgeon General concluded that cigarettes and other forms of tobacco (i.e., cigars,
pipes, and chewing tobacco) are addictive, and that nicotine is the drug in tobacco that causes
addiction. Nicotine provides an almost immediate “kick” by causing a discharge of epinephrine
from the adrenal cortex, which stimulates the central nervous system and endocrine glands.2
Nicotine changes heart rate, blood pressure, and breathing patterns. Children who are exposed to
nicotine could be at a higher risk for certain illnesses such as asthma, and babies could be at risk
for sudden infant death syndrome. Mood, memory, and appetite also may be affected in children
by exposure to nicotine.
Although nicotine is often portrayed as a stress reducer, it is a stimulant not a suppressant. Nicotine speeds up the heart, constricts blood vessels, and raises blood pressure. Carbon monoxide from the tobacco is absorbed in place of oxygen in the bloodstream. Nicotine can also cause lower estrogen levels in women and is know to be a major source of erectile dysfunction.3 Addiction to nicotine can result in withdrawal symptoms, including restlessness, cognitive and
attention deficits, irritability, cravings, sleep disturbances, changes in appetite, depression,
headaches, and other uncomfortable feelings.1,2 During cessation of smoking or periods of
craving, smokers also may have impairments in a wide range of psychomotor and cognitive
functions, such as language comprehension.2
Epidemiology: Each year more than 400,000 Americans die as a result of cigarette smoking.
One in every five deaths in the United States is smoking-related.4 An estimated 20.8 percent of
all adults (45.3 million people) smoke cigarettes in the United States. The cigarette smoking
estimates by age are as follows: 18–24 years (23.9%), 25–44 years (23.5%), 45–64 years
(21.8%), and 65 years or older (10.2%).4 Cigarette smoking is more common among men
(23.9%) than women (18.0%),4 although rates of smoking were similar for males and females
ages 12-17.4 The rate of smokeless tobacco use was significantly higher for men than for women
in 1995.5
Prevalence varies by race and ethnicity, with the prevalence of the smoking highest among American Indians/Alaska Natives (32.4%), followed by African Americans (23.0%), whites (21.9%), Hispanics (15.2%), and Asians – excluding Native Hawaiians and other Pacific Islanders (10.4%).4 Nicotine Addiction and Mental Illness: Several studies find high rates of smoking among
persons with mental illness. Persons with nicotine dependent disorder are about twice as likely
to suffer from another mental disorder.6 Similarly, persons who have mental disorders are about
twice as likely to smoke as others. Although they comprise an estimated 28 percent of the
population, persons who are mentally ill consume about 44 percent of all cigarettes smoked. Smoking rates are particularly high (75% to 95%) among people with schizophrenia.7 Nicotine Addiction and Substance Use: Use of illicit drugs and alcohol is more common
among current cigarette smokers than among nonsmokers. Among persons ages 12 or older, 20.4
percent of past-month cigarette smokers reported current use of an illicit drug compared with 4.2
percent of persons who were not current cigarette smokers.8 Past month alcohol use was reported
by 66.3 percent of current cigarette smokers compared with 45.8 percent of those who did not
use cigarettes in the past month. The association also was found with binge drinking (43.6% of
current cigarette users vs. 16.1% of current nonusers) and heavy drinking (16.0% vs. 3.8%,
Nicotine Addiction and Homelessness: As many as 75 percent of persons who are homeless
smoke, compared to 57 percent in a matched nonhomeless cohort.9 Because they are more likely
to practice high-risk smoking behaviors (e.g., smoking discarded cigarettes, tampering with
filters), smokers who are homeless are more susceptible to tobacco-related health complications
and infectious diseases.
In a Pittsburgh study of homeless persons receiving medical or social services at nine sites, 69 percent of the homeless clients were current smokers.10 Reports of tobacco use prevalence rates among homeless persons internationally have ranged from 75 to 85 percent, and are consistent with the high rate of mental illness and substance abuse seen among homeless patients in the United States and elsewhere.10,11 Treatment Approaches (Substance Abuse/Mental Health/Trauma/Homelessness):

Pharmacological treatment combined with behavioral treatment (including psychological support
and skills training to overcome high-risk situations), results in some of the highest long-term
abstinence from smoking rates. Medications used for smoking cessation, such as bupropion and
naltrexone, can also attenuate post cessation weight gain and could become additional strategies
for enhancing treatment success.2
There are also nicotine replacement therapies1 (NRTs), such as nicotine gum and the transdermal
nicotine patch, which were the first pharmacological treatments approved by the Food and Drug
Administration (FDA) for use in smoking cessation therapy. NRTs are used (in conjunction with
behavioral support) to relieve withdrawal symptoms. An added benefit is that these forms of
nicotine have little abuse potential since they do not produce the pleasurable effects of tobacco
products—nor do they contain the carcinogens and gases associated with tobacco smoke.
Behavioral treatments may enhance the effectiveness of NRTs and improve long-term
Pharmacological treatments other than NRTs are being studied. The antidepressant bupropion
was approved by the FDA in 1997 to help people quit smoking and is marketed as Zyban.
Varenicline tartrate (Chantix) is a new medication that recently received FDA approval for
smoking cessation. Scientists are also investigating the potential of a vaccine that targets nicotine
for use in relapse prevention. The nicotine vaccine is designed to stimulate the production of
antibodies that would block access of nicotine to the brain and prevent nicotine’s reinforcing
effects.1 Behavioral interventions play an integral role in smoking cessation treatment, either in conjunction with medication or alone.1 They employ a variety of methods to assist smokers in quitting, ranging from self-help materials to individual cognitive-behavioral therapy. These interventions teach individuals to recognize high-risk smoking situations, develop alternative coping strategies, manage stress, improve problem solving skills, as well as increase social support. Research has also shown that the more therapy is tailored to a person’s situation, the greater the chances are for success.1 Quitting smoking can be difficult. While people can be helped during the time an intervention is delivered, most intervention programs are short-term (one to three months). Within six months, 75–80 percent of people who try to quit smoking relapse.1.Research has now shown that extending treatment beyond the typical duration of a smoking cessation program can produce quit rates as high as 50 percent at one year.1 Major SAMHSA Activities/Resources:

● The NSDUH Report. November 15, 2007: Depression and the Initiation of Cigarette, Alcohol, and Other Drug Use among Young Adults: ● NSDUH: Cigarette Use among Blacks: 2005 and 2006: ● Youth Tobacco Sales: State Synar Enforcement Efforts and SAMHSA's Synar ● NSDUH: Work Absences and Past Month Cigarette Use: 2004 and 2005: ● Nicotine Effects on the Body at Family Guide: ● Clinical Preventive Services in Substance Abuse and Mental Health Update: From ● 2006 National Survey on Drug Use & Health: National Results: Chapter 4 Tobacco: ● Cigarette Use Among Pregnant Women and Recent Mothers: References:
1. U.S. Department of Health and Human Services, National Institute for Drug Abuse. Research
Report-Nicotine Addiction. Retrieved November 28, 2007 from ( NIH Pub. No. 01-4342. Bethesda, MD: NIDA, NIH, DHHS. Printed July, 1998. Reprinted Aug., 1998. 2. U.S. Department of Health and Human Services, National Institute for Drug Abuse. (2006). Cigarettes and other tobacco products [Info fact sheet]. Retrieved November 28, 2007, from 3. Jones, D. C. (2006). 12 step programs: Nicotine addiction and nicotine dependency. Self Growth, 2006. Retrieved November 28, 2007, from 4. Centers for Disease Control and Prevention. (2007). Adult cigarette smoking in the United States: Current estimates. Smoking and tobacco use [fact sheet]. Retrieved November 28, 2007, from 5. National Center for Chronic Disease Prevention and Health Promotion Tobacco Information and Prevention Sources (TIPS) (1996). 1995 National Household Survey on Drug Abuse, Tobacco Related Statistics, SAMSHA. Retrieved November 28, 2007, from 6. Schmitz, N., Kruse, J., & Kugler, J. (2003). Disabilities, quality of life, and mental disorders associated with smoking and nicotine dependence. American Journal of Psychiatry 160(9), 1670-1676. 7. Volkow, N. D. (2007). Addiction and Co-Occurring Mental Disorders. National Institute for Drug Abuse 21(2), Director’s Prospective. 8. Substance Abuse and Mental Health Services, Office of Applied Studies. (2006) National Survey on Drug Use and Health: National Results. Rockville, MD. Retrieved November 28, 2007 from 9. Spector, A., Hilary, Alpert, M.D. & Maher, K.H. (2007). Smoking cessation delivered by medical students is helpful to homeless population. Academic Psychiatry, 31:5, 402-405. 10. Connor, S.E., Herbert, M.I., Neal, S.M., Williams, J,T. (2002). Smoking cessation in homeless populations: there is a will, but is there a way? General Internal Medicine 17(5):369-372. 11. Folsom, D., Jeste, D.V. (2002). Schizophrenia in homeless persons: A systematic review of the literature. Acta Psychiatrica Scandinavica 105: 404-413.



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