Adolescent smoking remains a significant public health issue with 23% of high school seniors reporting smoking a cigarette in the past month and 14% smoking daily1
. Smoking rates are substantially higher among adolescents with concurrent substance use disorders (SUD’s). Previous studies with youth receiving SUD treatment consistently find that almost all (over 80%) report current tobacco use, most are daily smokers2–5
, and many become highly dependent, long-term tobacco users6–8
Despite frequent cessation attempts, few adolescents stop smoking on their own9
. Continued smoking is particularly likely among adolescents with substance abuse problems. For example, we have reported that 80% of those who smoked at the time of SUD treatment were still smoking four years later10
. In a recent investigation we found that greater alcohol use over an 8-year period following treatment was associated with higher smoking rates11
. However, even those with the best alcohol use outcomes had significantly elevated rates of smoking compared with the general population. Thus, adolescent smokers who receive treatment for SUD’s, but not their tobacco use, appear to be at heightened risk for smoking persistence.
Treating smoking during adolescence has the potential of preventing chronic tobacco use and the multitude of associated health risks. This concern is particularly acute for individuals with SUD’s given their heavy tobacco use. Tobacco-related health consequences may emerge relatively early as suggested by findings that respiratory problems were significantly more common among heavier smoking youth following SUD treatment3
. Synergistic effects of tobacco and other substances of abuse indicate that concurrent heavy use leads to substantially increased health risks12, 13
. The particular liability of individuals with SUD’s to these health consequences is highlighted by studies which have identified tobacco as a major contributor to mortality among adults treated for alcohol and other drug abuse14, 15
Concern regarding the significant health consequences observed for smokers with concomitant SUD’s is reflected in a growing body of research on this topic. A recent meta-analysis of studies with adults in addictions treatment or recovery concluded that tobacco treatment interventions were effective in promoting short-term (post-treatment) but not long-term (≥ 6-months) smoking cessation16
. Importantly, exposure to a tobacco cessation intervention while in SUD treatment was associated with an increased likelihood of long-term abstinence from drugs or alcohol. Thus, contrary to previous concerns17
, smoking cessation interventions during addictions treatment appeared to enhance rather than compromise long-term outcome. This conclusion is bolstered by other studies with adults that have found quitting smoking is associated with greater rates of alcohol and drug abstinence 12-months following SUD treatment18, 19
Possible mechanisms by which tobacco treatment interventions may support sobriety from alcohol and other drugs of abuse include reduced cue exposure, generalizability of relapse prevention techniques, increased sense of mastery, positive overall focus on health and change in lifestyle, or some other factor16
. The priming theory represents one theoretical model that may account for the observed findings. This model, based on classical conditioning principles, suggests that following paired use, the use of one substance may act as a cue to prime the use of the second substance. Support for the priming theory comes from studies that have found a positive relationship between smoking and drinking. For instance, York and Hirsch20
found that alcoholics who smoke cigarettes have a higher quantity and frequency of alcohol intake relative to non-smoking alcoholics. Similarly, heavy drinking among smokers has been associated with increased quantity of cigarette use21
and an increased likelihood of remaining a smoker22
. Thus, reduced smoking following a tobacco-focused intervention may limit exposure to substance use cues, thus leading to reduced substance involvement following treatment for alcohol and other drug use problems.
A growing literature demonstrates the value of smoking cessation intervention for adults with SUD’s. Despite evidence for negative health consequences and a clear need for treatment, few studies have evaluated smoking interventions with youth16
. A recent meta-analysis identified 48 controlled investigations of adolescent tobacco treatment23
. Of those referenced, only our recently published study24
examined tobacco cessation interventions in the context of adolescent substance abuse treatment. The trial compared a 6-session tobacco reduction and cessation intervention with a no-treatment control condition. Findings indicated significantly greater point prevalence abstinence at 3-months follow up among those in the treatment group compared to the waitlist control group. Thus, initial evidence supports the utility of addressing tobacco use at the time of adolescent SUD treatment.
The present investigation utilizes data from our recent clinical trial to examine the effect of the tobacco intervention on alcohol and drug use outcomes. We hypothesize that over a six month follow up period SUD youth assigned to the treatment condition would report significantly fewer days of alcohol and illicit drug use and significantly greater continuous abstinence from substance use than youth in the waitlist control condition. In addition, to assess the priming theory, we examined whether the effect of smoking treatment on substance use outcomes was mediated by changes in smoking behavior. Specifically, we hypothesized that reductions in rates of smoking would at least partially account for the relationship between receiving a smoking intervention and improved alcohol and other drug use outcomes. We believe the present investigation is the first to report on the effects of a tobacco use intervention on adolescent SUD treatment outcomes.