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Why do so many drug users smoke?
Journal of Substance Abuse Treatment 25 (2003) 43 – 49
Regular article
Why do so many drug users smoke? Robert M. McCool, MS a,*, Kimber Paschall Richter, PhD, MPH a,b a
Preventive Medicine and Public Health, Mail-Stop 1008, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA b Kansas Cancer Institute, University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66160, USA Received 20 September 2002; received in revised form 21 March 2003; accepted 10 April 2003
Abstract To better understand why most persons in drug treatment smoke, we explored patients’ views of the relationship between their smoking, methadone, and drug use. Recruiting from four methadone clinics, we held seven focus groups with 68 current smokers, and 10 individual interviews with former smokers. Sessions were audio-taped, transcribed, and coded. Participants were z18 years old, smoked z5 cigarettes per day, and had used prescription methadone for z2 years. Most patients linked smoking, methadone, and drug use in three ways. First, patients said smoking and drug use were complementary. Examples included smoking to reduce methadone aftertaste and using drugs to reduce smoking-related throat pain. Second, smoking and drug use were similar because they shared cues and withdrawal symptoms. Third, smoking differed from drug use because it had fewer acute consequences. Because smoking, methadone, and drug use are closely interrelated, future addictions research and treatment protocols should address them in combination. D 2003 Elsevier Inc. All rights reserved. Keywords: Smoking; Methadone; Addiction; Treatment; Nicotine
1. Introduction Only about 23.5% of U.S. adults smoke (Morbidity and Mortality Weekly Report, 2003). However, 71% of illicit drug users (Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2001), over 90% of alcohol inpatients (Bien & Burge, 1990), and up to 100% of methadone maintenance patients smoke (Chait & Griffiths, 1984). This leads to a high incidence of tobacco-related mortality among these groups. A 24-year retrospective study of patients in treatment for narcotics addiction found that smokers had death rates four times higher than non-smokers (Hser, Anglin, & Powers, 1993), and an 11-year longitudinal study of 845 inpatients found that smoking was a more likely cause of death than alcohol (Hurt et al., 1996). Smoking cessation intervention trials among substance users have been relatively ineffective with long-term abstinence rates of 12% – 0% (Burling, Seidner Burling, & Latini, 2001). Regular smoking has been linked to a number of physiological, environmental, and psychological factors (Mayhew, Flay, & Mott, 2000). These factors include genetic predisposition (True et al., 1997), peer influences (Fisher, Lichten-
* Corresponding author. Tel.: +1-913-588-2502; fax: +1-913-588-2780. E-mail address: [email protected] (R.M. McCool). 0740-5472/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00065-5
stein, Haire-Joshu, Morgan, & Rehberg, 1993), and smoking for pleasure (Leventhal & Cleary, 1980). However, little if any research has been conducted investigating why so many patients in addictions treatment smoke. Because so little is known about why patients smoke at such high prevalence, we used qualitative techniques to identify potential factors that might have been missed by survey methods. We examined patients’ observations of what is unique about methadone and other drugs that led the vast majority to smoke. Identifying the contexts and consequences of patient smoking may help us to develop more successful interventions in this population devastated by tobacco-related morbidity and mortality.
2. Materials and methods 2.1. Study design This paper is Study II of research exploring cigarette smoking among people in drug treatment. In Study I, Richter, McCool, Okuyemi, Mayo, & Ahluwalia (2002) reported patients’ interest in quitting smoking, cessation methods, and interest in long-term nicotine replacement therapy. We used focus groups, individual interviews, and brief questionnaires to collect qualitative and quantitative data. Below, we
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describe data collection and analysis for Study I, and how a subset of data was selected and coded for Study II. 2.2. Study I 2.2.1. Recruitment We recruited a convenience sample of patients from five methadone maintenance treatment (MMT) centers in an urban area of the Midwestern United States. Participants were 18 years or older, smoked or had smoked at least five cigarettes per day, and were enrolled continuously in MMT for at least the past 2 years. Of a total of 149 patients screened, 111 were invited to participate, and 78 actually attended. We conducted four focus groups among patients that had never tried to quit smoking (continuous smokers) and three focus groups among patients that had tried in the past but relapsed (relapsers). As there were few who had successfully quit, we conducted individual interviews with former smokers at their convenience. 2.2.2. Data collection Focus groups were conducted at patients’ clinics and lasted 2 hours. The authors (McCool and Richter) alternated as moderator and co-moderator. The moderator followed a guide consisting of eight to ten open-ended questions and asked follow-up questions to clarify participant comments. Guide questions were revised and added as new issues and themes emerged. The co-moderator took notes, summarized the groups’ discussion, and asked follow-up questions based on that summary. Interviews with former smokers lasted 1 –2 hours and followed a similar question guide. All focus group and interview participants completed a survey that collected information on demographics, smoking behaviors, and motivation for smoking cessation and reduction. We compensated participants $40.00 each and provided a meal to focus group participants. All sessions were audio taped and professionally transcribed. We compared transcriptions to audiotapes and corrected discrepancies. After corrections had been made, we matched the names of focus group participants with their recorded statements using the notes of the co-moderator. 2.2.3. Confidentiality To preserve confidentiality, participants’ names were replaced with pseudonyms in the transcripts and manuscripts. Additionally, each focus group was made up only of persons from a single clinic. 2.2.4. Analysis We used SPSS (SPSS Version 11.0, SPSS Inc., Chicago, IL) to analyze quantitative (survey) data. Study I qualitative analysis was conducted using QSR Nudist 4 (QSR International Pty Ltd., Melbourne, Australia) (QSR N4, 1998). Study I analysis identified 24 core themes related to interest in quitting, quit attempts, and other issues. Two observers coded transcripts using the 24 codes, which had been
developed during several rounds of coding and consultation. Some of these codes we developed before data collection (such as ‘‘cold turkey’’ as a strategy for quitting). Others emerged from analysis (such as ‘‘prayer’’ as a quit strategy). We assessed inter-rater reliability for the 24 core codes. To do so, we each coded a 10% randomly selected portion of all transcripts. For each portion, we independently noted whether particular codes did or did not occur. We calculated percentage of agreement for each portion; mean coding agreement was 83% (range 71% to 92%) with a ‘fair’(Bakeman & Gottman, 1986) kappa score of .57. 2.3. Study II 2.3.1. Data selection For the present study, we created a new data set by combining all comments that connected methadone or illicit drugs and tobacco. These data included comments from most of the continuous, relapsed, and former smokers in Study I. Additionally, we added statements derived from a QSR Nudist word-search of the term methadone. 2.3.2. Analysis We printed our new pool of comments and paraphrased them into bullet statements. These bulleted statements were then entered into an Excel file and coded. As in Study I, a number of themes emerged. Patients frequently talked about how tobacco was similar to or different from methadone, alcohol, and other drug use. Accordingly, after several rounds of coding and consultation, we categorized comments using four codes: Complementary, Similar, Different, and Unrelated. These primary codes identified patient comments that compared and contrasted smoking with methadone, alcohol, and other drug use.
3. Results 3.1. Sample characteristics The 78 participants in Study I included 34 continuous smokers, 34 relapsed smokers, and 10 former smokers. Participants’ mean age was 44 years; 58% were female, 78% described themselves as White, and mean treatment duration in MMT was 11 years. Although nearly 20% reported not finishing high school, another 56% reported completing some college. Smokers averaged 25 cigarettes per day (SD = 13); 61% smoked within 5 minutes of waking; and half of participants reported not smoking cigarettes for at least one day during the past year. Of the original 78 participants, 59 (76%) directly linked their smoking to their use of methadone, alcohol, and other drugs; and these 59 persons became the sole basis for analyses within Study II. Study II participants included relapsed, continuous, and former smokers. Patients said they smoked because it added or was complementary to their
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drug use, because it was similar, or because it was different from other drug use. A minority of two persons said their smoking and drug use were unrelated. 3.2. Smoking and drug use are complementary Thirty-nine different participants (66%) reported that smoking concurrently or within a short time of drug use enhanced both activities. A majority of these respondents emphasized that smoking made drug use more enjoyable, and a minority said that drug use made smoking more enjoyable. Thirty-eight persons thought that smoking was best with opiates or methadone, 10 persons said smoking was best with alcohol, and fewer said that smoking was most enjoyable with other drugs such as crack cocaine. Some participants said they smoked proportionately more after taking higher-than-normal doses of other drugs. A few participants pointed out their smoking became regular only after initiating frequent drug use. Paul was typical of those who found smoking and drug use complementary. He regarded smoking and drug use as though they were part of a single experience or ‘‘ritual.’’ He said each was less satisfying when not paired with the other. Paul said, ‘‘Methadone— narcotics. . .as soon as I’d shoot heroin. . .I’d want to. . .light up a cigarette. When I would drink beer, the first thing I wanted to do after. . .was have a cigarette. It seems like it all works together. . .the alcohol. . .the drugs—immediately after I do it I want to smoke cigarettes. . .’’ Most participants indicated that drug-related activities were more enjoyable when paired with smoking. For example, patients portrayed smoking as a valued activity they could share with peers and treatment staff alike. They also said smoking improved drug highs, enabled repose, and the deep state of relaxation they called the ‘‘nod.’’ Jennifer fantasized during a focus group, ‘‘A shot of dope and a cigarette would be very good right now. . .It’s cozy. It’s kind of like get a blanket and an ashtray. You already took your fifth big hit. A cigarette comes right on, and then here comes your nod, and a cigarette—my goodness.’’ Although the majority of patients asserted they smoked more after drug use, most were not very specific. Justin said, ‘‘I smoke more when I do other drugs—other than methadone—like speed, or something like that, I smoke a lot. . .I smoke more when I do crack.’’ A few participants did estimate their smoking increase relative to their drug use. The amounts reported varied dramatically. James, for example, noted that he smoked only one or two cigarettes before methadone dosing, but after, ‘‘I am fine to smoke four or five.’’ Joshua, however, provided a more extreme example. Joshua said, ‘‘Methadone makes me smoke more. [Between 4:30 and 9:00 a.m.] I’ll smoke two cigarettes, but after I get dosed. . .in the next hour [I] could probably smoke 30.’’ Similarly, Grace recalled her frequency of smoking increased as she augmented her use of methadone. Grace said, ‘‘The cravings are much worse. I used to double-dose [take
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twice the prescribed amount of medicine] on my methadone, and on those days. . .I could smoke double of what [I could on days that I took normal amounts of methadone].’’ Many clients said they used smoking to manage side effects of methadone and other drugs. Dylan disliked the flavor of methadone and smoked directly after dosing: ‘‘Methadone gives you a certain taste in your mouth and a cigarette seems to kill the [bad] taste. That is the reason that everybody smokes a cigarette the minute they get out the door [of the methadone clinic].’’ Other clients smoked to counter negative emotions accompanying methadone treatment or illicit drug use. Patients reported anxiety, boredom, malaise, anger, and fatigue as frequently accompanying both illicit and prescription drug use. Smoking helped them to relax, pass time, get ‘‘a little boost,’’ take a time out, forget problems, and focus on something positive (a cigarette). Allison summed up her experience, ‘‘The whole tenseness of running around to cop [obtain drugs], getting it and then doing it, and then. . .you could smoke and relax.’’ Finally, many patients such as Grace experienced methadone withdrawal daily, and used smoking to help. Grace said: ‘‘I actually, physically, feel a relief when I have cigarettes. Through withdrawals, or sometimes my methadone—if I’ve sweat too much, or [it] doesn’t carry me. . . the cigarettes actually give a physical relief [from opiate withdrawal].’’ Perhaps most surprising to interviewers were the patients who said methadone, alcohol, and other drugs helped them— or allowed them—to smoke. Samuel and Robert emphasized that methadone had analgesic and cough-suppressant properties. Samuel said, ‘‘We are drinking the equivalent of five bottles of codeine cough syrup every time we walk to that window [of the methadone pharmacy], so you can imagine how suppressed our cough reflex is and how good that cigarette feels. I used to smoke lights [but] on methadone I smoke the reds, because I couldn’t feel the lights anymore and every once in a while [when high on methadone] I buy nonfilters.’’ Robert agreed, ‘‘I think opiates in general create a hunger for tobacco. . .it masks the negative. Your chest doesn’t hurt. Your throat doesn’t hurt.’’ In a similar way, Brandon focused on alcohol and other drugs as an aid to smoking: ‘‘Hennesey [[whiskey] gave [me] the strength to smoke. . .getting high [on other drugs] made [my] body able to take the smoke.’’ In summary, patients said that smoking and other drugs provide mutual benefits and that both were better when used together. Smoking helped patients to manage the disliked flavor of methadone, the negative affect associated with drug use, and withdrawal issues. Similarly, patients liked that particularly methadone and alcohol helped them to smoke more with less cough and pain. 3.3. Smoking is similar to other drugs Twenty-eight persons (47%) explained their smoking in terms of its similarity to other drugs. Patients said that, like
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other drugs, smoking is an addiction that is sometimes beyond control and subject to denial. It also has similar effects, cues, withdrawal symptoms, and thought patterns as other drugs. Patients explained their smoking as an addiction in a number of ways. Some said they had ‘‘addictive personalit(ies)’’ that made smoking as compulsive for them as other drugs and activities. A lesser number reported feeling ‘‘double-addicted,’’ or bound to fulfill at least two addictions, with smoking being the more innocuous. At least one person said her smoking was ‘‘insane’’ and as strongly binding as her heroin addiction. Paul also explained his addiction in terms of his strong urge to smoke, ‘‘[I was digging] in the trash can and finding cigarette butts and stuff to roll up and smoke. . .it’s hard to explain, but anybody that is familiar with addiction, it [smoking] affects you the same way as a drug.’’ Later, Paul described the difficulty of admitting that addiction, ‘‘When you say, ‘oh, I like to smoke. . .’ your problem is that you don’t realize you’re addicted and that you’re fixing yourself, that’s all you’re doing when you’re smoking cigarettes.’’ Smoking had its own expected psychoactive effects. Madison compared the effect of smoking: ‘‘It’s [smoking is] not like a cocaine upper, it’s like coffee. It’s kind of a little boost.’’ Smoking and drug use shared cues and withdrawal symptoms. Places that cued both smoking and drugs included treatment clinics, billiards halls, gambling casinos, and bars. Mental states or withdrawal symptoms that cued both smoking and drug use included craving, irritability, stress, and fatigue. Catherine said these symptoms were so alike that treatment staff had warned her, ‘‘[Alcoholics Anonymous]. . .don’t want people trying to do all of that at once [quit smoking and drug use simultaneously]. It would be too much for anybody. You wouldn’t know what withdrawal symptoms were from drugs, alcohol, or cigarettes.’’ Patients said smoking and drug use led them to similar cognitions or ‘‘crazy drug addict thoughts.’’ Catherine gave an example of this, ‘‘They tell the alcoholics’ spouses, ‘don’t pour liquor down the drain—that just makes them want to drink even worse because they are mad at you, because now they have a reason to get drunk.’ So it’s the same thing, someone [my mother] throws the cigarettes away so that you can’t smoke. Your mind goes that you’re an adult—I can smoke if I want to. That’s ridiculous, but that’s the way our [addicted] minds seem to work.’’ Other ‘‘mental’’ similarities that participants reported between their smoking and drug use were smoking to find social acceptance, take risk, compete (‘‘you smoke two packs—I smoke four’’), gain the forbidden (‘‘that’s a game you’re playing with your head. . .you’re going to find a way to get it (if it is prohibited)’’), and to express self-image (I’m a smoker. . .that’s what I am.’’)
In summary, smoking and other drugs were thought to be similar in many ways. Smoking was perceived as a strong addiction like that experienced with other drug use. Like other drugs, smoking was thought to share situational, withdrawal, and cognitive cues to use. 3.4. Smoking is different from other drugs Differences between smoking and other drugs were also reported that might explain the high prevalence of smoking. At least 17 patients (29%) discussed these differences. Patients said that smoking has fewer or less acute hazardous effects than other drugs, and that smoking is an attractive alternative to illicit drugs that is used to lessen withdrawal, craving, and relapse. Participants emphasized that they and drug treatment staff tended to disregard the dangers of smoking while being more wary of illicit drug use. At least 24 persons said smoking is less important—and five said smoking is more difficult to quit—than other drugs. Contrasting the history of their smoking to other drug use, participants said they initiated smoking at an earlier age, smoked more frequently, and smoked for a longer period of their lives than they had used other drugs. Catherine said her smoking was, ‘‘a different kind of addiction than drugs were because you do it so many times a day.’’ Isabel added, ‘‘Honestly, quitting smoking was harder than quitting my heroin addiction. . .because my addiction to heroin wasn’t as long as my addiction to cigarettes. My cigarette addiction took me back to being [10] years old.’’ Several patients also emphasized that smoking was different and preferred to drug use because smoking was associated with fewer or less acute legal, social, economic, cognitive, and physical consequences. Allison: ‘‘Cigarettes are legal and you can buy them over-the-counter, whereas all of the drugs. . .are illegal and you can be arrested for having them. . .and long-term the effects of cigarettes are not immediate as compared to crack. . .You can have a heart attack from smoking crack one time, as compared to cigarettes that cause cumulative effects [after] years and years and years of smoking.’’ Olivia: ‘‘Alcohol makes you, and drugs too, can take you. . .where you’re combating, you’re crazy, you go to jail. Where cigarettes—you’re not going to jail. . .I’ve never seen anyone flip out on a cigarette. [laughter from other participants] Bite a cop!’’ Justin: ‘‘Crack is illegal and they put you in jail, plus it takes all of your money. Therefore I will deal with my drug addiction first and cigarettes second.’’ In this light, patients suggested smoking was a licit ‘‘comfort’’ they could use to allay withdrawal and a ‘‘good fallback’’ to prevent relapse to other drugs. Isabel explained her use of smoking as a means of avoiding relapse to heroin: ‘‘There would be moments where, no, absolutely not [could I make it without a cigarette], absolutely not. I
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just would break. I would do something crazy. I would do something wrong if I didn’t have that cigarette. Like, it’s better to have a cigarette than to go out and use heroin.’’ Likewise, Miranda reported why it was so easy for her to overlook the hazards of smoking while she used illicit drugs, ‘‘If you’re worried about trying to buy illegal drugs and you are sick and you are going through withdrawal, then the last thing you’re going to think about is whether a cigarette is good for you or not. All you are going to think about is whether it is going to help you wait, is it going to calm your nerves—so you’re going to smoke. . .I don’t think I could quit smoking if I was still doing illegal drugs. I don’t think I would or could.’’ Dissimilar to their illicit drug use experience, at least 11 participants reported peers in treatment, doctors, and health care staff accepted their smoking as normal, relatively insignificant, or actually beneficial. Jasmine said, ‘‘[In the clinic] you’re socializing. Like all of us—we smoke cigarettes. We could just sit here and smoke cigarettes and drink pop [until] three o’clock.’’ Lauren gave an example of her physicians’ reaction to her suggestion that she quit smoking, ‘‘Those doctors [said] ‘Yeah, that’s all right.’ When you ask a MD if you should stop smoking, and they look at your methadone. . .they act like it’s a joke.’’ Likewise, Chris observed that his psychiatrist had recommended his smoking (‘‘might be a way for me to relax and give me something to do’’), and that in treatment environments, ‘‘it’s coffee, sugar, and cigarettes. . . they are the mild addictions.’’ Maintaining some participants’ smoking behaviors were perceived differences between smoking and other drug use. Many patients found smoking was more enjoyable, and others emphasized that—unlike other drug use—they did not feel instructed by God to quit smoking. Finally, a large number indicated that smoking did not seem to affect methadone metabolism the way that some other drugs did. Alex explained, ‘‘Crack cocaine. . .takes the methadone right out of your body and makes you sick [of opiate withdrawal]. That is. . .why I think most of the people in here. . .want to quit the crack first, because the cigarettes don’t do that to you. They don’t take the methadone out of your body. . .’’ In summary, participants noted a wide variety of differences between smoking and other drug use. Smoking was perceived as less harmful; more socially, medically, and religiously accepted, more pleasurable, and less likely to disrupt methadone maintenance than other drugs. 3.5. Smoking is unrelated to methadone and other drug use Only two smokers (3%) said smoking, methadone, and other drug use were unrelated. When Jake was asked how he felt being in a methadone maintenance program affected his smoking, he answered, ‘‘I don’t think it had. [They were] different habits, different addictions.’’ Similarly, Lindsey reported that methadone, ‘‘didn’t have any bearing on it
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[smoking] at all,’’ and it didn’t make quitting smoking ‘‘easier or harder.’’
4. Discussion This study sought to discover patient perceptions of the relationship between smoking, methadone, and other drugs. Patients linked these elements in three ways. First, they said smoking and drug use each made the other more enjoyable. Complementary smoking reduced methadone aftertaste and improved drug highs. Conversely, complementary drug use also reduced pain and coughing associated with smoking. Second, participants explained their smoking as similar to other drug use in being a strong addiction, with cues and withdrawal symptoms like other drugs. Third, patients described their smoking as different from drug use. Patients perceived that—unlike other drugs—smoking has fewer acute negative consequences, usually is used for a longer period of life, and is viewed as a legitimate product by patients and staff. Our study supported past findings. For example, as has been found for other smokers (Tate, Pomerleau, & Pomerleau, 1994), our patients reported smoking automatically, to relax, avoid withdrawal, for energy, to socialize, for pleasure, and for something to do with their mouths and hands. However, our analysis suggests that drug users often smoke for the same reasons that they use drugs. For example, our participants appeared to smoke as a result of the same types of negative affects that have increased cravings in other addictions patients (Taylor, Harris, Singleton, Moolchan, & Heishman, 2000). Our patients also appeared to maintain smoking addiction as a response to stress and setting, as has been theorized to sustain other drug addictions (Kreek, 2001). As with psychiatric patients (Lucksted, Dixon, & Sembly, 2000), patients additionally smoked because they felt it was acceptable to their peer group, and because they felt cessation was unsupported. Many of our patients reported smoking and craving proportionately more before, during, and after drug use. Increased smoking directly after drinking has been previously documented among alcoholics (Henningfield, Chait, & Griffiths, 1984) and moderate drinkers (Burton & Tiffany, 1997). Also observed has been smoking proportionate to cocaine and heroin dose by patients enrolled in MMT (Frosch, Shoptaw, Nahom, & Jarvik, 2000). Just as some of our participants reported their smoking frequency correlated with their methadone dose, experiments have shown that augmented methadone doses result in immediate (Chait & Griffiths, 1984) and long-term (Schmitz, Grabowski, & Rhoades, 1994) smoking increases. It has also been found that smoking decreases when methadone dose is reduced (Bigelow, Stitzer, Griffiths, & Liebson, 1981). Our patients commonly reported smoking most heavily directly after using methadone. This is in line with limited research (Schmitz et al., 1994) showing the greatest
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share of smoking is completed in the 4 hours following methadone administration. The purpose of this study was to explore the broad variety of influences that may exist between methadone, illicit drug use, and smoking. It also lays the groundwork for future epidemiological and experimental studies. This analysis is limited in that it relies on self-report data taken from a non-random sample of persons. Groups and interviews were facilitated by two persons who may have unconsciously solicited responses or asked questions differently. Finally, participants were all enrolled in MMT. The extent to which results will generalize to persons in other treatment modalities is unknown. Cross-sectional, longitudinal, and experimental studies will be required to ascertain the distribution of potential influences reported here, and to determine the degree to which data is representative of the broader treatment community. Many implications for future treatment and research follow from these findings. Of particular interest are drug users who smoke as part of the drug-use ritual, to manage methadone taste and withdrawal, to counter drug-related emotions, and to improve drug highs such as the ‘‘nod.’’ For patients who are cued to use drugs or who feel the druguse ritual is not complete without smoking, it will be crucial to treat smoking addiction as a part of drug treatment. For those methadone and drug treatment patients who use smoking to manage negative aspects of treatment such as taste or withdrawal, it will be very important to find harm-free alternatives that can fill these roles. These may be as simple as providing taste-cleansing mints after methadone dosage or as complex as readjusting methadone doses to avoid withdrawal or psychoactive abuse symptoms. Similarly, patients using smoking to manage negative emotions associated with their drug habit might be provided psychiatric or psychological assistance as necessary to fill that need. Equally important is the finding that smokers may use methadone and alcohol to help reduce the downsides of smoking. In extreme cases of nicotine addiction, and in cases where smoking is accompanied by discomfort such as sore throat and coughing, smokers may actually be using or continuing methadone and alcohol in order to smoke. This is a phenomenon that little or no previous research has examined, but which holds strong potential for understanding and treatment in both smoking and drug use populations. Given the harm that both smoking and abusive drug use can cause, extensive examination of patient motivations is warranted. Smoking has long been understood to lead to an addiction like those caused by other drugs (Henningfield, Clayton, & Pollin, 1990) with similar factors affecting initiation, abstinence, and relapse. It also causes immense morbidity and mortality when compared with other drug use (McGinnis & Foege, 1993). Smoking and drug use may be reciprocally enhanced behaviors. Further smoking cessation treatment should be encouraged in all substance use clinics. Future research should measure the prevalence and conse-
quences of patients smoking and using drugs simultaneously, as well as best treatment practices.
Acknowledgments The authors would like to thank the patients and staff of participating methadone treatment clinics for their assistance and support in this research. We would also like to thank Matthew Mayo for his assistance with Study I; that made Study II possible. This study was funded by the Center for Substance Abuse Prevention (6 T26 STO8354), the National Institute on Drug Abuse (K01 DA00450); and was approved by the University of Kansas Medical Center’s Institutional Review Board.
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Richter, K. P., McCool, R. M., Okuyemi, K. S., Mayo, M. S., & Ahluwalia, J. S. (2002). Patients’ views on smoking cessation and tobacco harm reduction during drug treatment. Nicotine and Tobacco Research, 4 (Suppl 2), S175 – S182. Schmitz, J. M., Grabowski, J., & Rhoades, H. (1994). The effects of high and low doses of methadone on cigarette smoking. Drug and Alcohol Dependence, 34 (3), 237 – 242. Tate, J. C., Pomerleau, C. S., & Pomerleau, O. F. (1994). Pharmacological and non-pharmacological smoking motives: a replication and extension. Addiction, 89 (3), 321 – 330. Taylor, R. C., Harris, N. A., Singleton, E. G., Moolchan, E. T., & Heishman, S. J. (2000). Tobacco craving: intensity-related effects of imagery scripts in drug abusers. Experimental and Clinical Psychopharmacology, 8 (1), 75 – 87. True, W. R., Heath, A. C., Scherrer, J. F., Waterman, B., Goldberg, J., Lin, N., Eisen, S. A., Lyons, M. J., & Tsuang, M. T. (1997). Genetic and environmental contributions to smoking. Addiction, 92 (10), 1277 – 1287.
Regular article
Why do so many drug users smoke? Robert M. McCool, MS a,*, Kimber Paschall Richter, PhD, MPH a,b a
Preventive Medicine and Public Health, Mail-Stop 1008, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA b Kansas Cancer Institute, University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66160, USA Received 20 September 2002; received in revised form 21 March 2003; accepted 10 April 2003
Abstract To better understand why most persons in drug treatment smoke, we explored patients’ views of the relationship between their smoking, methadone, and drug use. Recruiting from four methadone clinics, we held seven focus groups with 68 current smokers, and 10 individual interviews with former smokers. Sessions were audio-taped, transcribed, and coded. Participants were z18 years old, smoked z5 cigarettes per day, and had used prescription methadone for z2 years. Most patients linked smoking, methadone, and drug use in three ways. First, patients said smoking and drug use were complementary. Examples included smoking to reduce methadone aftertaste and using drugs to reduce smoking-related throat pain. Second, smoking and drug use were similar because they shared cues and withdrawal symptoms. Third, smoking differed from drug use because it had fewer acute consequences. Because smoking, methadone, and drug use are closely interrelated, future addictions research and treatment protocols should address them in combination. D 2003 Elsevier Inc. All rights reserved. Keywords: Smoking; Methadone; Addiction; Treatment; Nicotine
1. Introduction Only about 23.5% of U.S. adults smoke (Morbidity and Mortality Weekly Report, 2003). However, 71% of illicit drug users (Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2001), over 90% of alcohol inpatients (Bien & Burge, 1990), and up to 100% of methadone maintenance patients smoke (Chait & Griffiths, 1984). This leads to a high incidence of tobacco-related mortality among these groups. A 24-year retrospective study of patients in treatment for narcotics addiction found that smokers had death rates four times higher than non-smokers (Hser, Anglin, & Powers, 1993), and an 11-year longitudinal study of 845 inpatients found that smoking was a more likely cause of death than alcohol (Hurt et al., 1996). Smoking cessation intervention trials among substance users have been relatively ineffective with long-term abstinence rates of 12% – 0% (Burling, Seidner Burling, & Latini, 2001). Regular smoking has been linked to a number of physiological, environmental, and psychological factors (Mayhew, Flay, & Mott, 2000). These factors include genetic predisposition (True et al., 1997), peer influences (Fisher, Lichten-
* Corresponding author. Tel.: +1-913-588-2502; fax: +1-913-588-2780. E-mail address: [email protected] (R.M. McCool). 0740-5472/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00065-5
stein, Haire-Joshu, Morgan, & Rehberg, 1993), and smoking for pleasure (Leventhal & Cleary, 1980). However, little if any research has been conducted investigating why so many patients in addictions treatment smoke. Because so little is known about why patients smoke at such high prevalence, we used qualitative techniques to identify potential factors that might have been missed by survey methods. We examined patients’ observations of what is unique about methadone and other drugs that led the vast majority to smoke. Identifying the contexts and consequences of patient smoking may help us to develop more successful interventions in this population devastated by tobacco-related morbidity and mortality.
2. Materials and methods 2.1. Study design This paper is Study II of research exploring cigarette smoking among people in drug treatment. In Study I, Richter, McCool, Okuyemi, Mayo, & Ahluwalia (2002) reported patients’ interest in quitting smoking, cessation methods, and interest in long-term nicotine replacement therapy. We used focus groups, individual interviews, and brief questionnaires to collect qualitative and quantitative data. Below, we
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describe data collection and analysis for Study I, and how a subset of data was selected and coded for Study II. 2.2. Study I 2.2.1. Recruitment We recruited a convenience sample of patients from five methadone maintenance treatment (MMT) centers in an urban area of the Midwestern United States. Participants were 18 years or older, smoked or had smoked at least five cigarettes per day, and were enrolled continuously in MMT for at least the past 2 years. Of a total of 149 patients screened, 111 were invited to participate, and 78 actually attended. We conducted four focus groups among patients that had never tried to quit smoking (continuous smokers) and three focus groups among patients that had tried in the past but relapsed (relapsers). As there were few who had successfully quit, we conducted individual interviews with former smokers at their convenience. 2.2.2. Data collection Focus groups were conducted at patients’ clinics and lasted 2 hours. The authors (McCool and Richter) alternated as moderator and co-moderator. The moderator followed a guide consisting of eight to ten open-ended questions and asked follow-up questions to clarify participant comments. Guide questions were revised and added as new issues and themes emerged. The co-moderator took notes, summarized the groups’ discussion, and asked follow-up questions based on that summary. Interviews with former smokers lasted 1 –2 hours and followed a similar question guide. All focus group and interview participants completed a survey that collected information on demographics, smoking behaviors, and motivation for smoking cessation and reduction. We compensated participants $40.00 each and provided a meal to focus group participants. All sessions were audio taped and professionally transcribed. We compared transcriptions to audiotapes and corrected discrepancies. After corrections had been made, we matched the names of focus group participants with their recorded statements using the notes of the co-moderator. 2.2.3. Confidentiality To preserve confidentiality, participants’ names were replaced with pseudonyms in the transcripts and manuscripts. Additionally, each focus group was made up only of persons from a single clinic. 2.2.4. Analysis We used SPSS (SPSS Version 11.0, SPSS Inc., Chicago, IL) to analyze quantitative (survey) data. Study I qualitative analysis was conducted using QSR Nudist 4 (QSR International Pty Ltd., Melbourne, Australia) (QSR N4, 1998). Study I analysis identified 24 core themes related to interest in quitting, quit attempts, and other issues. Two observers coded transcripts using the 24 codes, which had been
developed during several rounds of coding and consultation. Some of these codes we developed before data collection (such as ‘‘cold turkey’’ as a strategy for quitting). Others emerged from analysis (such as ‘‘prayer’’ as a quit strategy). We assessed inter-rater reliability for the 24 core codes. To do so, we each coded a 10% randomly selected portion of all transcripts. For each portion, we independently noted whether particular codes did or did not occur. We calculated percentage of agreement for each portion; mean coding agreement was 83% (range 71% to 92%) with a ‘fair’(Bakeman & Gottman, 1986) kappa score of .57. 2.3. Study II 2.3.1. Data selection For the present study, we created a new data set by combining all comments that connected methadone or illicit drugs and tobacco. These data included comments from most of the continuous, relapsed, and former smokers in Study I. Additionally, we added statements derived from a QSR Nudist word-search of the term methadone. 2.3.2. Analysis We printed our new pool of comments and paraphrased them into bullet statements. These bulleted statements were then entered into an Excel file and coded. As in Study I, a number of themes emerged. Patients frequently talked about how tobacco was similar to or different from methadone, alcohol, and other drug use. Accordingly, after several rounds of coding and consultation, we categorized comments using four codes: Complementary, Similar, Different, and Unrelated. These primary codes identified patient comments that compared and contrasted smoking with methadone, alcohol, and other drug use.
3. Results 3.1. Sample characteristics The 78 participants in Study I included 34 continuous smokers, 34 relapsed smokers, and 10 former smokers. Participants’ mean age was 44 years; 58% were female, 78% described themselves as White, and mean treatment duration in MMT was 11 years. Although nearly 20% reported not finishing high school, another 56% reported completing some college. Smokers averaged 25 cigarettes per day (SD = 13); 61% smoked within 5 minutes of waking; and half of participants reported not smoking cigarettes for at least one day during the past year. Of the original 78 participants, 59 (76%) directly linked their smoking to their use of methadone, alcohol, and other drugs; and these 59 persons became the sole basis for analyses within Study II. Study II participants included relapsed, continuous, and former smokers. Patients said they smoked because it added or was complementary to their
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drug use, because it was similar, or because it was different from other drug use. A minority of two persons said their smoking and drug use were unrelated. 3.2. Smoking and drug use are complementary Thirty-nine different participants (66%) reported that smoking concurrently or within a short time of drug use enhanced both activities. A majority of these respondents emphasized that smoking made drug use more enjoyable, and a minority said that drug use made smoking more enjoyable. Thirty-eight persons thought that smoking was best with opiates or methadone, 10 persons said smoking was best with alcohol, and fewer said that smoking was most enjoyable with other drugs such as crack cocaine. Some participants said they smoked proportionately more after taking higher-than-normal doses of other drugs. A few participants pointed out their smoking became regular only after initiating frequent drug use. Paul was typical of those who found smoking and drug use complementary. He regarded smoking and drug use as though they were part of a single experience or ‘‘ritual.’’ He said each was less satisfying when not paired with the other. Paul said, ‘‘Methadone— narcotics. . .as soon as I’d shoot heroin. . .I’d want to. . .light up a cigarette. When I would drink beer, the first thing I wanted to do after. . .was have a cigarette. It seems like it all works together. . .the alcohol. . .the drugs—immediately after I do it I want to smoke cigarettes. . .’’ Most participants indicated that drug-related activities were more enjoyable when paired with smoking. For example, patients portrayed smoking as a valued activity they could share with peers and treatment staff alike. They also said smoking improved drug highs, enabled repose, and the deep state of relaxation they called the ‘‘nod.’’ Jennifer fantasized during a focus group, ‘‘A shot of dope and a cigarette would be very good right now. . .It’s cozy. It’s kind of like get a blanket and an ashtray. You already took your fifth big hit. A cigarette comes right on, and then here comes your nod, and a cigarette—my goodness.’’ Although the majority of patients asserted they smoked more after drug use, most were not very specific. Justin said, ‘‘I smoke more when I do other drugs—other than methadone—like speed, or something like that, I smoke a lot. . .I smoke more when I do crack.’’ A few participants did estimate their smoking increase relative to their drug use. The amounts reported varied dramatically. James, for example, noted that he smoked only one or two cigarettes before methadone dosing, but after, ‘‘I am fine to smoke four or five.’’ Joshua, however, provided a more extreme example. Joshua said, ‘‘Methadone makes me smoke more. [Between 4:30 and 9:00 a.m.] I’ll smoke two cigarettes, but after I get dosed. . .in the next hour [I] could probably smoke 30.’’ Similarly, Grace recalled her frequency of smoking increased as she augmented her use of methadone. Grace said, ‘‘The cravings are much worse. I used to double-dose [take
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twice the prescribed amount of medicine] on my methadone, and on those days. . .I could smoke double of what [I could on days that I took normal amounts of methadone].’’ Many clients said they used smoking to manage side effects of methadone and other drugs. Dylan disliked the flavor of methadone and smoked directly after dosing: ‘‘Methadone gives you a certain taste in your mouth and a cigarette seems to kill the [bad] taste. That is the reason that everybody smokes a cigarette the minute they get out the door [of the methadone clinic].’’ Other clients smoked to counter negative emotions accompanying methadone treatment or illicit drug use. Patients reported anxiety, boredom, malaise, anger, and fatigue as frequently accompanying both illicit and prescription drug use. Smoking helped them to relax, pass time, get ‘‘a little boost,’’ take a time out, forget problems, and focus on something positive (a cigarette). Allison summed up her experience, ‘‘The whole tenseness of running around to cop [obtain drugs], getting it and then doing it, and then. . .you could smoke and relax.’’ Finally, many patients such as Grace experienced methadone withdrawal daily, and used smoking to help. Grace said: ‘‘I actually, physically, feel a relief when I have cigarettes. Through withdrawals, or sometimes my methadone—if I’ve sweat too much, or [it] doesn’t carry me. . . the cigarettes actually give a physical relief [from opiate withdrawal].’’ Perhaps most surprising to interviewers were the patients who said methadone, alcohol, and other drugs helped them— or allowed them—to smoke. Samuel and Robert emphasized that methadone had analgesic and cough-suppressant properties. Samuel said, ‘‘We are drinking the equivalent of five bottles of codeine cough syrup every time we walk to that window [of the methadone pharmacy], so you can imagine how suppressed our cough reflex is and how good that cigarette feels. I used to smoke lights [but] on methadone I smoke the reds, because I couldn’t feel the lights anymore and every once in a while [when high on methadone] I buy nonfilters.’’ Robert agreed, ‘‘I think opiates in general create a hunger for tobacco. . .it masks the negative. Your chest doesn’t hurt. Your throat doesn’t hurt.’’ In a similar way, Brandon focused on alcohol and other drugs as an aid to smoking: ‘‘Hennesey [[whiskey] gave [me] the strength to smoke. . .getting high [on other drugs] made [my] body able to take the smoke.’’ In summary, patients said that smoking and other drugs provide mutual benefits and that both were better when used together. Smoking helped patients to manage the disliked flavor of methadone, the negative affect associated with drug use, and withdrawal issues. Similarly, patients liked that particularly methadone and alcohol helped them to smoke more with less cough and pain. 3.3. Smoking is similar to other drugs Twenty-eight persons (47%) explained their smoking in terms of its similarity to other drugs. Patients said that, like
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other drugs, smoking is an addiction that is sometimes beyond control and subject to denial. It also has similar effects, cues, withdrawal symptoms, and thought patterns as other drugs. Patients explained their smoking as an addiction in a number of ways. Some said they had ‘‘addictive personalit(ies)’’ that made smoking as compulsive for them as other drugs and activities. A lesser number reported feeling ‘‘double-addicted,’’ or bound to fulfill at least two addictions, with smoking being the more innocuous. At least one person said her smoking was ‘‘insane’’ and as strongly binding as her heroin addiction. Paul also explained his addiction in terms of his strong urge to smoke, ‘‘[I was digging] in the trash can and finding cigarette butts and stuff to roll up and smoke. . .it’s hard to explain, but anybody that is familiar with addiction, it [smoking] affects you the same way as a drug.’’ Later, Paul described the difficulty of admitting that addiction, ‘‘When you say, ‘oh, I like to smoke. . .’ your problem is that you don’t realize you’re addicted and that you’re fixing yourself, that’s all you’re doing when you’re smoking cigarettes.’’ Smoking had its own expected psychoactive effects. Madison compared the effect of smoking: ‘‘It’s [smoking is] not like a cocaine upper, it’s like coffee. It’s kind of a little boost.’’ Smoking and drug use shared cues and withdrawal symptoms. Places that cued both smoking and drugs included treatment clinics, billiards halls, gambling casinos, and bars. Mental states or withdrawal symptoms that cued both smoking and drug use included craving, irritability, stress, and fatigue. Catherine said these symptoms were so alike that treatment staff had warned her, ‘‘[Alcoholics Anonymous]. . .don’t want people trying to do all of that at once [quit smoking and drug use simultaneously]. It would be too much for anybody. You wouldn’t know what withdrawal symptoms were from drugs, alcohol, or cigarettes.’’ Patients said smoking and drug use led them to similar cognitions or ‘‘crazy drug addict thoughts.’’ Catherine gave an example of this, ‘‘They tell the alcoholics’ spouses, ‘don’t pour liquor down the drain—that just makes them want to drink even worse because they are mad at you, because now they have a reason to get drunk.’ So it’s the same thing, someone [my mother] throws the cigarettes away so that you can’t smoke. Your mind goes that you’re an adult—I can smoke if I want to. That’s ridiculous, but that’s the way our [addicted] minds seem to work.’’ Other ‘‘mental’’ similarities that participants reported between their smoking and drug use were smoking to find social acceptance, take risk, compete (‘‘you smoke two packs—I smoke four’’), gain the forbidden (‘‘that’s a game you’re playing with your head. . .you’re going to find a way to get it (if it is prohibited)’’), and to express self-image (I’m a smoker. . .that’s what I am.’’)
In summary, smoking and other drugs were thought to be similar in many ways. Smoking was perceived as a strong addiction like that experienced with other drug use. Like other drugs, smoking was thought to share situational, withdrawal, and cognitive cues to use. 3.4. Smoking is different from other drugs Differences between smoking and other drugs were also reported that might explain the high prevalence of smoking. At least 17 patients (29%) discussed these differences. Patients said that smoking has fewer or less acute hazardous effects than other drugs, and that smoking is an attractive alternative to illicit drugs that is used to lessen withdrawal, craving, and relapse. Participants emphasized that they and drug treatment staff tended to disregard the dangers of smoking while being more wary of illicit drug use. At least 24 persons said smoking is less important—and five said smoking is more difficult to quit—than other drugs. Contrasting the history of their smoking to other drug use, participants said they initiated smoking at an earlier age, smoked more frequently, and smoked for a longer period of their lives than they had used other drugs. Catherine said her smoking was, ‘‘a different kind of addiction than drugs were because you do it so many times a day.’’ Isabel added, ‘‘Honestly, quitting smoking was harder than quitting my heroin addiction. . .because my addiction to heroin wasn’t as long as my addiction to cigarettes. My cigarette addiction took me back to being [10] years old.’’ Several patients also emphasized that smoking was different and preferred to drug use because smoking was associated with fewer or less acute legal, social, economic, cognitive, and physical consequences. Allison: ‘‘Cigarettes are legal and you can buy them over-the-counter, whereas all of the drugs. . .are illegal and you can be arrested for having them. . .and long-term the effects of cigarettes are not immediate as compared to crack. . .You can have a heart attack from smoking crack one time, as compared to cigarettes that cause cumulative effects [after] years and years and years of smoking.’’ Olivia: ‘‘Alcohol makes you, and drugs too, can take you. . .where you’re combating, you’re crazy, you go to jail. Where cigarettes—you’re not going to jail. . .I’ve never seen anyone flip out on a cigarette. [laughter from other participants] Bite a cop!’’ Justin: ‘‘Crack is illegal and they put you in jail, plus it takes all of your money. Therefore I will deal with my drug addiction first and cigarettes second.’’ In this light, patients suggested smoking was a licit ‘‘comfort’’ they could use to allay withdrawal and a ‘‘good fallback’’ to prevent relapse to other drugs. Isabel explained her use of smoking as a means of avoiding relapse to heroin: ‘‘There would be moments where, no, absolutely not [could I make it without a cigarette], absolutely not. I
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just would break. I would do something crazy. I would do something wrong if I didn’t have that cigarette. Like, it’s better to have a cigarette than to go out and use heroin.’’ Likewise, Miranda reported why it was so easy for her to overlook the hazards of smoking while she used illicit drugs, ‘‘If you’re worried about trying to buy illegal drugs and you are sick and you are going through withdrawal, then the last thing you’re going to think about is whether a cigarette is good for you or not. All you are going to think about is whether it is going to help you wait, is it going to calm your nerves—so you’re going to smoke. . .I don’t think I could quit smoking if I was still doing illegal drugs. I don’t think I would or could.’’ Dissimilar to their illicit drug use experience, at least 11 participants reported peers in treatment, doctors, and health care staff accepted their smoking as normal, relatively insignificant, or actually beneficial. Jasmine said, ‘‘[In the clinic] you’re socializing. Like all of us—we smoke cigarettes. We could just sit here and smoke cigarettes and drink pop [until] three o’clock.’’ Lauren gave an example of her physicians’ reaction to her suggestion that she quit smoking, ‘‘Those doctors [said] ‘Yeah, that’s all right.’ When you ask a MD if you should stop smoking, and they look at your methadone. . .they act like it’s a joke.’’ Likewise, Chris observed that his psychiatrist had recommended his smoking (‘‘might be a way for me to relax and give me something to do’’), and that in treatment environments, ‘‘it’s coffee, sugar, and cigarettes. . . they are the mild addictions.’’ Maintaining some participants’ smoking behaviors were perceived differences between smoking and other drug use. Many patients found smoking was more enjoyable, and others emphasized that—unlike other drug use—they did not feel instructed by God to quit smoking. Finally, a large number indicated that smoking did not seem to affect methadone metabolism the way that some other drugs did. Alex explained, ‘‘Crack cocaine. . .takes the methadone right out of your body and makes you sick [of opiate withdrawal]. That is. . .why I think most of the people in here. . .want to quit the crack first, because the cigarettes don’t do that to you. They don’t take the methadone out of your body. . .’’ In summary, participants noted a wide variety of differences between smoking and other drug use. Smoking was perceived as less harmful; more socially, medically, and religiously accepted, more pleasurable, and less likely to disrupt methadone maintenance than other drugs. 3.5. Smoking is unrelated to methadone and other drug use Only two smokers (3%) said smoking, methadone, and other drug use were unrelated. When Jake was asked how he felt being in a methadone maintenance program affected his smoking, he answered, ‘‘I don’t think it had. [They were] different habits, different addictions.’’ Similarly, Lindsey reported that methadone, ‘‘didn’t have any bearing on it
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[smoking] at all,’’ and it didn’t make quitting smoking ‘‘easier or harder.’’
4. Discussion This study sought to discover patient perceptions of the relationship between smoking, methadone, and other drugs. Patients linked these elements in three ways. First, they said smoking and drug use each made the other more enjoyable. Complementary smoking reduced methadone aftertaste and improved drug highs. Conversely, complementary drug use also reduced pain and coughing associated with smoking. Second, participants explained their smoking as similar to other drug use in being a strong addiction, with cues and withdrawal symptoms like other drugs. Third, patients described their smoking as different from drug use. Patients perceived that—unlike other drugs—smoking has fewer acute negative consequences, usually is used for a longer period of life, and is viewed as a legitimate product by patients and staff. Our study supported past findings. For example, as has been found for other smokers (Tate, Pomerleau, & Pomerleau, 1994), our patients reported smoking automatically, to relax, avoid withdrawal, for energy, to socialize, for pleasure, and for something to do with their mouths and hands. However, our analysis suggests that drug users often smoke for the same reasons that they use drugs. For example, our participants appeared to smoke as a result of the same types of negative affects that have increased cravings in other addictions patients (Taylor, Harris, Singleton, Moolchan, & Heishman, 2000). Our patients also appeared to maintain smoking addiction as a response to stress and setting, as has been theorized to sustain other drug addictions (Kreek, 2001). As with psychiatric patients (Lucksted, Dixon, & Sembly, 2000), patients additionally smoked because they felt it was acceptable to their peer group, and because they felt cessation was unsupported. Many of our patients reported smoking and craving proportionately more before, during, and after drug use. Increased smoking directly after drinking has been previously documented among alcoholics (Henningfield, Chait, & Griffiths, 1984) and moderate drinkers (Burton & Tiffany, 1997). Also observed has been smoking proportionate to cocaine and heroin dose by patients enrolled in MMT (Frosch, Shoptaw, Nahom, & Jarvik, 2000). Just as some of our participants reported their smoking frequency correlated with their methadone dose, experiments have shown that augmented methadone doses result in immediate (Chait & Griffiths, 1984) and long-term (Schmitz, Grabowski, & Rhoades, 1994) smoking increases. It has also been found that smoking decreases when methadone dose is reduced (Bigelow, Stitzer, Griffiths, & Liebson, 1981). Our patients commonly reported smoking most heavily directly after using methadone. This is in line with limited research (Schmitz et al., 1994) showing the greatest
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share of smoking is completed in the 4 hours following methadone administration. The purpose of this study was to explore the broad variety of influences that may exist between methadone, illicit drug use, and smoking. It also lays the groundwork for future epidemiological and experimental studies. This analysis is limited in that it relies on self-report data taken from a non-random sample of persons. Groups and interviews were facilitated by two persons who may have unconsciously solicited responses or asked questions differently. Finally, participants were all enrolled in MMT. The extent to which results will generalize to persons in other treatment modalities is unknown. Cross-sectional, longitudinal, and experimental studies will be required to ascertain the distribution of potential influences reported here, and to determine the degree to which data is representative of the broader treatment community. Many implications for future treatment and research follow from these findings. Of particular interest are drug users who smoke as part of the drug-use ritual, to manage methadone taste and withdrawal, to counter drug-related emotions, and to improve drug highs such as the ‘‘nod.’’ For patients who are cued to use drugs or who feel the druguse ritual is not complete without smoking, it will be crucial to treat smoking addiction as a part of drug treatment. For those methadone and drug treatment patients who use smoking to manage negative aspects of treatment such as taste or withdrawal, it will be very important to find harm-free alternatives that can fill these roles. These may be as simple as providing taste-cleansing mints after methadone dosage or as complex as readjusting methadone doses to avoid withdrawal or psychoactive abuse symptoms. Similarly, patients using smoking to manage negative emotions associated with their drug habit might be provided psychiatric or psychological assistance as necessary to fill that need. Equally important is the finding that smokers may use methadone and alcohol to help reduce the downsides of smoking. In extreme cases of nicotine addiction, and in cases where smoking is accompanied by discomfort such as sore throat and coughing, smokers may actually be using or continuing methadone and alcohol in order to smoke. This is a phenomenon that little or no previous research has examined, but which holds strong potential for understanding and treatment in both smoking and drug use populations. Given the harm that both smoking and abusive drug use can cause, extensive examination of patient motivations is warranted. Smoking has long been understood to lead to an addiction like those caused by other drugs (Henningfield, Clayton, & Pollin, 1990) with similar factors affecting initiation, abstinence, and relapse. It also causes immense morbidity and mortality when compared with other drug use (McGinnis & Foege, 1993). Smoking and drug use may be reciprocally enhanced behaviors. Further smoking cessation treatment should be encouraged in all substance use clinics. Future research should measure the prevalence and conse-
quences of patients smoking and using drugs simultaneously, as well as best treatment practices.
Acknowledgments The authors would like to thank the patients and staff of participating methadone treatment clinics for their assistance and support in this research. We would also like to thank Matthew Mayo for his assistance with Study I; that made Study II possible. This study was funded by the Center for Substance Abuse Prevention (6 T26 STO8354), the National Institute on Drug Abuse (K01 DA00450); and was approved by the University of Kansas Medical Center’s Institutional Review Board.
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