Introduction to the Theme Issue on Smoking and Substance Abuse

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The public health and economic consequences of cigarette smoking are well established. Nearly 46 million people smoke in the U.S. (Department of Health and Human Services [DHHS], 2001) and 430,000 die annually from smoking related disease (Leshner, 1998). Tobacco smoking is both a public health and clinical problem with great physical and mental health consequences. Smoking is a risk factor for numerous cancers, as well as for heart disease, stroke, emphysema, and respiratory infections (National Institute on Drug Abuse, 1998). Tobacco use rapidly leads to addiction with associated biological brain changes that make quitting difficult for many (Scragg, Wellman, Laugesen, & DiFranza, 2008; Brody, et al., 2006). Economic costs of smoking were estimated at $157 billion dollars in 1999 (Centers for Disease Control and Prevention [CDC], 2002), approaching costs associated with alcohol abuse and exceeding those associated with illicit drug use (Harwood, Fountain, & Livermore, 1998). This theme issue on smoking and substance abuse focuses on this association, including the factors that have led to the high association (neurobiological to treatment system) and the range of tobacco control strategies to address this problem (public policy to clinical interventions). There continues to be a great need for true parity to provide coverage for tobacco addiction treatment services.

Two narratives frame this theme issue concerning smoking and substance abuse that include public health and clinical intervention initiatives. The first is the story of decreasing smoking behavior in the general population in the United States as a result of tobacco control public health strategies. From the 1964 Surgeon General's report on Smoking and Health (Department of Health Education and Welfare, 1964) to the present, smoking prevalence among adults decreased from 40% to about 20% (CDC, 2008). This public health achievement was accomplished with great effort and focus on both individual smoker risks and the serious health risks to non-smokers due to exposure to environmental tobacco smoke. Early congressional attempts at regulating tobacco products were unsuccessful, as they were often undermined by the efforts of the tobacco industry (Warner, 2006). Gains were made, halting at first and later cascading, as the public health sector focused on tobacco policies to address the growing health concerns over tobacco use at a population level. These tobacco policies worked in the areas of education, incentive, and regulation (Walsh & Gordon, 1986). Educational policies inform the general public through government reports, advertisements, and warning labels, while economic incentive policies include taxation and subsidies. Regulatory policies prohibit smoking in public places and in the workplace, the sale of tobacco to minors, possession of tobacco by youth, as well as other use and purchase laws (Warner, 2006). In the context of many broad and diverse tobacco control public health efforts, these policy approaches have succeeded in dramatically reducing smoking in the U. S.

The second narrative is the continuing high rates of smoking in subgroups, and particularly in persons with substance abuse problems. Lasser et al., (2000) estimated that 44% of all cigarettes smoked in the U.S. were smoked by persons with a current mental health diagnosis. Compared to a rate of 20% in the general population, smoking prevalence is 30% among persons with major depression, 33% among those with generalized anxiety disorder, 34% among those with alcohol disorders, and 52% among those with drug use disorders (Grant et al., 2004). Persons with substance abuse and dependence smoke at higher rates than the general population (Kaiman, 1998; Sobell, Sobell, & Agrawal, 2002), and at higher rates than persons with other common co-morbid psychiatric disorders (Grant et al., 2004).

Tobacco dependence clinical treatment guidelines identify substance abusers as a population that needs to be addressed and targeted for tobacco dependence intervention (Fiore et al. …