June 2018

The nicotine conundrum

A tobacco treatment specialist has advised frontline workers to help their clients quit smoking and withdraw from their use of other drugs at the same time.

Historically, frontline workers have not always encouraged clients to simultaneously withdraw from tobacco and other drugs.

The belief was that trying to stop tobacco use might interfere with the process of withdrawing from a primary drug of dependence.

What’s more, for NSP workers, who also have a high rate of smoking, smoking with clients has sometimes been a useful way to build trust.

Associate Professor Colin Mendelsohn, a tobacco treatment specialist from the School of Public Health and Community Medicine at the University of New South Wales, says people who use substances have higher health risks from smoking than other groups because they begin smoking earlier and smoke more cigarettes.

“In a study following people who use heroin over 24 years, those who smoked had a mortality rate four times higher than those who didn’t smoke”, he says. “Substance users who smoke are more likely to die from a smoking-related disease than their primary drug use.”

“Many people with alcohol and other drug problems overcome their primary addiction, only to then die from a tobacco-related illness.”

Why are smoking rates higher in people who use drugs?

Colin says several reasons have been suggested for the high rates of smoking. Some suggest smoking is a ‘gateway’ to illicit drugs and is part of the culture of drug-taking. Another possibility is a shared genetic predisposition for dependence on tobacco and other drugs.

“The use of addictive drugs also releases a brain chemical (dopamine) creating a sense of pleasure and this could enhance enjoyment of tobacco when used together. Another possibility is that some people might use tobacco to relieve mental health symptoms,” Colin says.

He points out that smokers who use drugs and have infections can add to their disease burden.

For example, now that HIV infection can be managed with treatment, people living with HIV lose more years of life from smoking than from HIV.

“The harmful effects of smoking are magnified in patients with HIV. People living with HIV lose more years of life from smoking-related disease than from HIV/AIDs,” he says.

People with hepatitis C related to drug use also have high rates of smoking. Now that hepatitis C can be cured, Colin anticipates smokers will lose more years of life to tobacco-related illness.

Why is tobacco harm reduction important for people who use other drugs?

Tobacco harm reduction is especially important for smokers who use other drugs because they have very low quit rates. Colin says switching to a safer alternative source of nicotine substantially delivers far fewer toxins and reduces the risk of smoking-related disease.

He says the focus is best kept on preventing harm and not on preventing the use of nicotine. Nicotine alone, at doses found in smoking cigarettes and in using e-cigarettes (vaping) is relatively benign, except in pregnancy and perhaps in adolescence.

Harm reduction for smoking is no different to other harm reduction strategies widely used in addiction medicine, such as methadone for people who use heroin, NSP/needle exchange and medically supervised injecting rooms.

Providing adequate low-risk nicotine can both help people quit cigarettes and help with their other drug withdrawal strategies.

Associate Professor Colin Mendelsohn

Associate Professor Colin Mendelsohn

“Providing adequate low-risk nicotine can both help people quit cigarettes and help with their other drug withdrawal strategies,” Colin says.

People who are withdrawing from heroin can have difficulty quitting for a range of reasons:

  • Methadone can produce more intense tobacco cravings and withdrawal symptoms.
  • Smoking can be used to decrease anxiety and depression in people who also have mental illness and high levels of stress.
  • Ongoing nicotine use can improve brain function in people with mental illness, especially schizophrenia.
  • A strong culture of smoking exists among people who use other drugs.
  • People with low levels of self-efficacy have more difficulty refusing nicotine.

Colin says that providing access to low-risk sources of nicotine, such as e-cigarettes, would help to alleviate these problems. In addition, e-cigarettes are much cheaper than smoking, which would assist people who use other drugs and are often on low incomes.

What about e-cigarettes?

An Australian Government parliamentary committee has recently stated that the ban on e-cigarettes containing nicotine should remain in place (see the Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia).

Colin does not agree with the ban.

“Electronic cigarettes with nicotine should be made legally available in Australia as consumer products for adult smokers who are unable to quit with conventional treatments.

“It is illegal to possess or use nicotine liquid for vaping in Australia without a prescription, but most doctors will not write nicotine prescriptions,” he says.

He points out that e-cigarettes have helped millions of smokers overseas to quit and smoking rates are falling in countries where vaping is widely available, whereas smoking rates have stalled in Australia for the last few years.

He says studies of people who use drugs show they have high rates of interest in, and use of, e-cigarettes compared with the general population.

“Quit rates are very low in this group, so e-cigarettes could have a useful role for people who use drugs.

“E-cigarettes provide the nicotine and the ‘smoking experience’ but with only a tiny fraction of the risk and this makes vaping a far safer alternative to smoking for smokers who are unable to quit cigarettes.”

He says the UK Royal College of Physicians has estimated the hazard to health arising from long-term vapour inhalation from e-cigarettes is unlikely to exceed 5 per cent of the harm from smoking tobacco.

Are there other harm reduction tools for tobacco?

Dr Alex Wodak, President of the Australian Drug Law Reform Foundation, strongly agrees that harm reduction is very important.

“Rates of smoking are not just higher in people who use drugs, they are sky high,” he says. “What we also know is that not only is there a high rate of commencing smoking, but there’s a very high rate of retention in smoking and a low rate of giving up smoking.”

Alex says current nicotine reduction therapies – for example, chewing gums, lozenges and patches – were a big advance when introduced, but they do not deliver enough nicotine compared with cigarettes.

“In harm reduction and in public health, there’s no point in having a safer product or a safer alternative risk behaviour, if that alternative risk behaviour isn’t also attractive.”

Alex says devices are more attractive to smokers when they deliver more nicotine and mimic some of the ritual behaviour and physical sensations of smoking. He explains that there is a whole new array of reduced-risk products such as e-cigarettes and the “heat-not-burn” devices that heat tobacco rather than burn it.

He says these are so effective the tobacco industry views these products as “disruptive technologies”.

As an example, after the recent release of a heat-not-burn device in Japan, cigarette sales have decreased 27 per cent over the last two years. Alex says there has never been such an astonishing and rapid reduction in smoking rates.

“These devices heat the tobacco and people inhale that vapour, which is much less toxic than cigarette smoke. These devices have not yet been released in Australia, but I’m sure they’ll come here.”

How can NSP workers help smokers who use other drugs?

Alex says that everyone working with people who use drugs should encourage their clients to quit smoking.

NSP workers should also be encouraged to quit themselves. Those who cannot quit should consider switching from cigarettes to nicotine lozenges, sprays, patches, or to lower-risk options such as e-cigarettes or heat-not-burn devices when they become available.

Colin says health professionals who smoke are less likely to offer counselling to clients to help them quit, but it is important to implement effective counselling strategies.

Julie Milland

Counselling strategies to help people quit smoking include:

  • Describing withdrawal symptoms and cravings and exploring ways of managing these (e.g. distraction strategies such as doing exercise).
  • Agreeing on a quit date and promoting the “not-a-puff” rule (i.e. committing to not taking a single puff of a cigarette after the quit date).
  • Addressing barriers to quitting and how to overcome these (e.g. weight gain or stress).
  • Identifying smoking triggers and discussing strategies to cope with them (e.g. minimal or no alcohol in the early weeks of a quit attempt).
  • Getting support from family and friends, support services and printed materials.
  • Promoting lifestyle changes, such as exercise and avoiding high-risk situations.