Yuri Schukin

History

Originated in California in the early 1980's. Recovering alcoholics Los Angles began metting, an indepent group was started in San Francisco. Originally smokers anonymous. Bakersfield in 1986, incorporated after conference. Smokers Anonymous trademark was owned by, switched to nicotine anonymous.

450 meetings in 21 countries.

1. An elected National Board of Directors and a set of by-laws. The 12 traditions, adapted from AA, are the fundamental principles guiding the governance of the Fellowship. The Board meets and conducts business regularly by telephone conference and at face-to-face meetings. 2. A national office or clearinghouse; Nicotine Anonymous World Services, located in San Francisco; and a website, which provides information about the organization 3. Nicotine Anonymous: The Book (Nicotine Anonymous, 1992), a work that applies the basic 12-step principles and traditions to nicotine addiction and that includes many testimonials from members 4. Official written materials—pamphlets, forms—providing information to members or prospective members, including tips for gaining freedom from nicotine and suggestions on how to start a meeting 5. An annual worldwide conference 6. A quarterly newsletter, Seven Minutes, published by the National Office 7. A regularly updated list of meetings, provided by the national clearinghouse and by the website, which serves as a resource for members or for any interested smoker

Sponsorship not as prevalent. Average meeting size is about seven people. Sponsors and lifetime attendance not emphasized as much as in AA.

Ranked 12th in size among 13 programs listed by Makela (1996).

Although, relative to alcoholism, smoking causes greater mortality (USDHHS, 1990), alcoholism leads to much greater proximal social and psychological pathology

Nicotine Anonymous evolved in a historical context very different from that of AA. At the time that AA was evolving, there were very few options for the alcohol abuser. Detoxification was available in a few hospital settings, but there was little in the way of outpatient psychiatric or psychological treatments, and alcoholism was viewed as a product of weak character. AA provided an explanation for alcoholism and offered a free program for assistance.

Nicotine Anonymous arrived when there were already numerous treatment options for smokers (Orleans, 1995; Pinney, 1995), ranging from free self-help booklets to intensive, multisession, multicomponent programs (Lando, 1993). At the present time, scores of wellcontrolled efficacy trials have been conducted on cessation intervention, and several metaanalyses (e.g., Fiore, Smith, Jorneby, & Baker, 1994; Kottke, Brekke, Solberg, & Hughes, 1989; The Smoking Cessation Clinical Practice Guideline Panel and Staff, 1996) have summarized the outcomes of these trials. Much is known about what interventions do and do not work. Laboratory and clinical research have produced a wealth of data on nicotine addiction (e.g., USDHHS, 1988), and several theories of smoking have been proposed

The mutual-help movement can have public health impact because it engages significant numbers of sufferers. How does Nicotine Anonymous compare with proprietary and nonprofit programs as a resource for smokers? No-cost (or very low cost) group programs are sponsored by the Seventh Day Adventist Church, The American Cancer Society, The American Lung Association, and the American Heart Association. Only rough estimates are available about the number of programs they offer. Pinney (1995) reported that these four organizations estimated that they served 284,000 smokers in 1993. Many commercial programs are now available, and a few of these are offered nationally (Lando, 1993). Some of these programs, for example, Smokeless and Smoke Stoppers, are licensed to hospitals or corporations. As of the early 1990s, Smokeless was being offered by 500 hospitals and 1,000 corporations, and Smoke Stoppers was being offered by 250 hospitals and more than 200 companies (Lando, 1993). Clearly, there are many group cessation programs available because there are also numerous regional and local programs, for example, those offered by hospitals or managed care organizations. Nicotine Anonymous, in comparison, is a relatively small player. If each of the approximately 450 meetings reaches 25 smokers over the course of a year, then 11,250 would be served. Nicotine Anonymous meetings, however, are unique in at least one important way: They are held every week, and smokers or ex-smokers may come whenever they wish. All of the nonprofit and commercial programs are conducted episodically, and participants must enter or start at the beginning. Nicotine Anonymous is available ad lib. Nicotine Anonymous also appears to be growing, whereas Pinney (1995, p. 510) notes that reports from group-program vendors suggest that demand is either flat or declining.

attractive to and useful for severely addicted, heavier smokers and smokers with substance abuse comorbidities, especially alcoholism.

Pharmacological methods, noticeably nicotine replacement therapy (NRT), are often recommended for heavy smokers. NRT is clearly efficacious (e.g., Fiore et al., 1994; Silagy, Mant, Fowler, & Lodge, 1994) and sometimes has been shown to be a particular benefit for the more addicted smoker (Silagy et al., 1994). For several reasons—for example, cost, side effects—NRT is limited in applicability and even for those who can and choose to use it, is quite time limited. Although many smokers do not see group treatment as useful (Lichtenstein & Hollis, 1992) or may not be comfortable with the 12-step approach, some dependent heavy smokers who do not succeed with NRT may turn to Nicotine Anonymous. Nicotine Anonymous' stance regarding pharmacological cessation products is not yet known, although some members reported using nicotine patches.

Given that the first Nicotine Anonymous meetings were formed by recovering alcoholics, it might be expected that the program would continue to be an attractive option for smokers with alcohol or other substance-abuse problems, especially those with prior 12-step experience. In the first edition of the Nicotine Anonymous: The Book (Nicotine Anonymous, 1992), it was noted that 25% of respondents had prior 12-step experience, and I suspect this was usually with AA. (Information in the Nicotine Anonymous: The Book is based on a convenience sample of unknown size.) Alcohol abuse and smoking have been shown to be related in a number of studies (Bobo, 1989; Hurt, Eberman, Slade, & Karan, 1993). Smokers who had benefitted from a 12-step program for another addiction would likely be comfortable with Nicotine Anonymous. Recovering alcoholic smokers are a subgroup in need of services, and little research has been directed at this population (Hughes, 1996; Martin et al., 1997).

nonymous attendees would not be smoking, that is, they would be in the maintenance phase (DiClemente et al., 1991). Our limited experience with a few Nicotine Anonymous groups contradicts this; several members were still smoking. More systematic information on where members are in the change process and the extent to which attendance may motivate cessation attempts would be valuable. At a descriptive level, it would be of interest to measure the demographics and smoking history (including prior quit attempts) of Nicotine Anonymous members. Such data might be compared both with data from smokers in the general population and with smokers attending other group-cessation programs. For example, group-cessation programs typically attract more women. Is this also true for Nicotine Anonymous?

In summary, the emergence of Nicotine Anonymous as a resource is consistent with secular trends encouraging mutual-help groups and with tobacco use being construed as an addictive behavior. Although Nicotine Anonymous has grown steadily over the past 15 years, its future is uncertain. It may fill an important niche for the dependent, recovering alcoholic smoker. A number of research issues concerning Nicotine Anonymous participant characteristics, the stability and variability of meetings, and the degree to which Nicotine Anonymous departs from classic 12-step principles and procedures seem worthy of consideration.

Makela, K. (1996). Alcoholics anonymous as a mutual-help movement. Madison: University of Wisconsin Press.

Emrick, C. D., Tonigan, J. S., Montgomery, H., & Little, L. (1993). Alcoholics anonymous: What is currently known? In B. S. McCrady & W. R. Miller (Eds.), Research on alcoholics anonymous: Opportunities and alternatives (pp. 41-76). New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Miller, W. R., & McCrady, B. S. (1993). The importance of research on alcoholics anonymous. In B. S. McCrady & W. R. Miller (Eds.), Research on alcoholics anonymous: Opportunities and alternatives (pp. 3-12). New Brunswick, NJ: Rutgers Center of Alcoholic Studies.

Effectiveness

Acupuncture, hypnosis, inpatient treatment, and Twelve-Step therapy (Nicotine Anonymous) have not been shown effective thus far.

Effectiveness is 9% to 40%.

Stead LF, Lancaster T. Group behavior therapy programmes for smoking cessation. Cochrane Database Syst Rv 2002;3:CD001007.

Heishman SJ. Henningfield JE, Kendler KS, et al. Society for Research on Nicotine and Tobacco. Third Annual Scientific Conference, Nashville Tennessee, USA. 13-14 June 1997. Addiction 1998;93:907-23.

Effectiveness in former addicts/alcoholics

A total of 205 (113 male, 92 female) nonhospitalized recovering alcoholics with > 3 months of continuous abstinence from alcohol and drugs and relatively heavy tobacco dependence (Fagerstrom Tolerance Questionnaire score = 7.7; mean number of cigarettes per day, 26.8; mean number of years smoked, 24.4) were randomized to standard treatment (ST) American Lung Association quit program plus nicotine anonymous meetings (n = 70), behavioral counseling plus physical exercise (BEX; n = 72), or behavioral counseling plus nicotine gum (BNIC; n = 63). A 3 x 4 repeated measures design was used to evaluate the effectiveness of the interventions on smoking outcome at baseline, posttreatment, and 6- and 12-month follow-ups. Self-reported smoking status was verified with biochemical and informant report. Verified self-report indicated that significantly more smokers in BEX quit by posttreatment (60%) than in either BNIC (52%) or ST (31%), chi 2 (2, N = 205) = 17.85, p < .01, but not at the 6-month (29%, 27%, and 21%, respectively) or 12-month (27%, 27%, and 26%, respectively) follow-up. Only 4% (7 of 188) relapsed to alcohol or drugs. Alcohol relapse did not differ by treatment group or smoking status. Length of alcohol abstinence was not associated with smoking cessation outcome.

Do Smokers With Current or Past Alcoholism Need Different or More Intensive Treatment?

Comorbidity

It is recommended that alcoholics and drug addicts in recovery also ... better restult attempting smoking cessation early in recovery

Individuals with mental illness and addiction comprise at least half of the patients in most mental health treatment systems.

In combination with medication

Combining psychosocial and pharmacological treatments clearly increases success.

Comparison

Current outpatient smoking therapies include self-help programs (Nicotine Anonymous), cognitive-behavioral group therapy, nicotine replacement therapies (path, gum, sparay, inhaler) and bupropion (Zyban). Success in achieving smoking abstinence with these methods ranges from 9% to 40% in different studies.4-7 Inpatient smoking treatment consults represent another model for treating smoking dependence. Treament programs based on inpatient consults on medical and surgical wards have reported quit rates of 15% at 12 months (compared to 8% quit rates in controls). An alternative approach to these programs is residential therapy. 4 - Stead LF, Lancaster T. Group behavior therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2002;3:CD001007. 5 - Effectiveness of a 24-hour transdermal nicotine patch in conjunction with a cognitive behavioural programme: one year outcome. Addiction. 1997;92:27-31. 6 - Silagy C. Mant D. Fowelr G. Lancaster T. Nicotine replacement therapy for smoking cessation. Tobaacco Addiction Module, Cochrane Database Syst Rev. 2001;3:CD000146. 7 -Heisman SJ. Henningfield Je. Kenlder KS., et al. Society for Research on Nicotine and Tobacco. Third Annual Scientific Conference, Nashbille, Tennesse, USA, 13-14 June 1997. 1998:93:907-923.

Comparison with other programs

• Intentions to quit smoking in substance-abusing teens exposed to a tobacco program
• An Update on Smoking Cessation

Prospective evaluation of three smoking interventions in 205 recovering alcoholics

A total of 205 (113 male, 92 female) nonhospitalized recovering alcoholics with > 3 months of continuous abstinence from alcohol and drugs and relatively heavy tobacco dependence (Fagerstrom Tolerance Questionnaire score = 7.7; mean number of cigarettes per day, 26.8; mean number of years smoked, 24.4) were randomized to standard treatment (ST) American Lung Association quit program plus nicotine anonymous meetings (n = 70), behavioral counseling plus physical exercise (BEX; n = 72), or behavioral counseling plus nicotine gum (BNIC; n = 63). A 3 x 4 repeated measures design was used to evaluate the effectiveness of the interventions on smoking outcome at baseline, posttreatment, and 6- and 12-month follow-ups. Self-reported smoking status was verified with biochemical and informant report. Verified self-report indicated that significantly more smokers in BEX quit by posttreatment (60%) than in either BNIC (52%) or ST (31%), chi 2 (2, N = 205) = 17.85, p < .01, but not at the 6-month (29%, 27%, and 21%, respectively) or 12-month (27%, 27%, and 26%, respectively) follow-up. Only 4% (7 of 188) relapsed to alcohol or drugs. Alcohol relapse did not differ by treatment group or smoking status. Length of alcohol abstinence was not associated with smoking cessation outcome.

Tobacco users openness to Spritual Resources

Patient spiritual resources are increasingly included in the treatment of medical conditions such as cancers and alcohol and drug dependence, but use of spiritual resources is usually excluded from tobacco dependence treatment. We hypothesized that this omission may be linked to perceived resistance from smokers. To examine this hypothesis, we conducted a pilot survey to assess whether current smokers would consider spiritual, including religious, resources helpful if they were planning to quit. Smokers at least 18 years of age at Oregon Health & Science University in Portland, Oregon, (N = 104) completed a brief survey of smoking behaviors and spiritual beliefs. None were attempting to quit. Of these individuals, 92 (88%) reported some history of spiritual resources (spiritual practice or belief in a Higher Power), and of those respondents, 78% reported that using spiritual resources to quit could be helpful, and 77% reported being open to having their providers encourage use of spiritual resources when quitting. Results of logistic regression analysis indicated that those aged 31-50 years (OR = 3.3), those over age 50 years (OR = 5.4), and women (OR = 3.4) were significantly more likely to have used spiritual resources in the past. Of the 92 smokers with any history of spiritual resources, those smoking more than 15 cigarettes/day were significantly more receptive to provider encouragement of spiritual resources in a quit attempt (OR = 5.4). Our data are consistent with overall beliefs in the United States about spirituality and recent trends to include spirituality in health care. We conclude that smokers, especially heavier smokers, may be receptive to using spiritual resources in a quit attempt and that spirituality in tobacco dependence treatment warrants additional investigation and program development.

Dependence

The most appropriate primary treatment focus for tobacco dependence involves an understanding of addiction and the characteristic cognitive concepts and behaviors seen with other drug dependency problems. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), a diagnosis of tobacco dependence is appropriate when three or more of the identifiers of dependence are present. These include tolerance, withdrawal, use for a longer period than intended, multiple unsuccessful attempts to quit, activities given up or reduced because of substance use, and continued use in spite of health and personal consequences. The vast majority of tobacco users recognize these signs of dependence.

Other addictions

Because of the high morbidity and mortality that alcoholic smokers experience from tobacco-caused diseases, treatment for tobacco dependence among alcoholics is warranted. Much progress has been made during the last decade in addressing tobacco dependence in alcoholism treatment units. Treatment of tobacco dependence in alcoholic smokers does not seem to cause excessive relapse to drinking and, in fact, stopping smoking may enhance abstinence from drinking. Therefore, treatment for alcoholic smokers should take place whenever and wherever the patient comes in contact with the health care system. Because alcoholic smokers as a rule are more dependent on nicotine than their nonalcoholic counterparts, they may need more intensive pharmacotherapy and behavioral therapy. Because many of them have experienced 12-step approaches to recovery, that same technology can be used to initiate and maintain abstinence from tobacco use. Moreover, several pharmacologic options exist to treat tobacco dependence in alcoholic smokers. However, the efficacy of several pharmacologic therapies for alcoholic smokers needs to be tested. In addition, further research is needed on effective treatments for recovering alcoholics of various racial/ethnic backgrounds.

Purpose of review: The rates of tobacco addiction in individuals with psychiatric disorders (mental illness and addiction) continue to remain alarmingly high despite substantial decreases in smoking in the general population. Recent findings suggest that tobacco addiction treatment can be effective for smokers with psychiatric disorders, but will require both clinical interventions and systems changes. There is both an immediate need to address tobacco in this population and to expand research agendas to include the many remaining clinical questions for this population.

Recent findings: Nearly half of all cigarettes consumed in the United States are smoked by individuals with psychiatric disorders, who are at two to three times the risk of developing tobacco-related medical illnesses. Recent international studies have found high rates of heavy smoking among those with psychiatric disorders similar to those in the United States. Under-recognition and under-treatment of tobacco addiction in this population continues to be common despite the availability of effective management approaches. Smokers with psychiatric disorders are a broad treatment population that requires treatment specificity according to subtypes. Nicotine replacement medication, bupropion, atypical anti-psychotics, and modified psychosocial treatments can improve outcomes. The effective model programs and system changes that have begun to address tobacco in this population have often not been published, disseminated, or replicated.

Summary: There continue to be relatively few treatment studies for this population, and the existing studies have small sample sizes. Research should test whether effective treatments used in the general population will work for this population. Program development and system changes should be described and evaluated.

Psychosocial Treatments

Behavioral therapy focuses on building skills to resist relapse such as developing incompatible behaviors (e.g., exercise), coping thoughts, refusal skills, etc. This therapy increases quit rates by a factor of 1.5 to 2.1.

Social support identifies persons who will be encouraging about cessation, finds “buddies” who are also either trying to quit or have done so, etc. Social support increases quit rates by a factor of 1.3 to 1.5.

Behavioral and supportive therapies were developed initially for use in individual or group therapy formats. However, less than 5% of smokers will attend such therapy (Table 3). Written materials do not appear to be effective; however, delivering behavior therapy via the telephone increases quit rates by a factor of 1.2.

Although less effective, this format is so much more acceptable that it has a bigger impact than group or individual counseling. Whether therapy could be delivered via the Internet is being tested. Acupuncture, hypnosis, inpatient treatment, and Twelve-Step therapy (Nicotine Anonymous) have not been shown effective thus far.

The most important aspect to smoking cessation is maintaining the motivation to make multiple attempts. Thus, quit attempts should be thought of like practice sessions in learning a new skill—at some point one hopes to "get it right," but one should not put undue hope on any single given quit attempt, and take solace in knowing the probability of success increases with each try. Given that 1) stopping smoking is the single most important thing one can do to improve their health; 2) smoking cessation treatment doubles or triples quit rates; and 3) smoking treatment is the "gold standard" of cost-effective treatments, smoking cessation is not the time to try to reduce costs by allocating treatments only to those with special difficulties. All smokers should be encouraged to access a treatment. Typically, state health departments are the best source of information on local cessation resources. In addition, since the efficacy of brief advice, pharmacotherapies, and psychological therapies all are dose related—the more intense the treatment, the greater the success rate —smokers should be encouraged to participate in as intensive therapies as possible.

Relationship to Family

Both drinking and smoking are recognized by many respondents as imposing burdens on the family. Family members often comment on drinking and smoking, and make suggestions about cutting down or quitting.

Recognition of addictive nature of smoking

A notable omission in the clinical or empirical literature on 12-step programs is Nicotine Anonymous. The addictive nature of cigarette smoking and nicotine was only recently given public and scientific recognition (U.S. Department of Health and Human Services [USDHHS], 1988), although several workers in the field had so construed it for many years (e.g., Russell, 1976). There is now scientific consensus that nicotine is addictive by any reasonable definition (Henningfield, Cohen, & Pickworth, 1993; Kaplan, Orleans, Perkins, & Pierce, 1995; USDHHS, 1988).

Much of the public continues to view smoking as a habit (Cunningham, Sobell, Freedman, & Sobell, 1994) and quitting smoking as primarily a matter of choice and motivation. For these reasons, perhaps, mutual help groups were slow in coming to cigarette smoking, but come they have. Nicotine Anonymous groups have sprung up across the U.S. and in many other countries, and a worldwide organization now exists.

Cessation tips

A convenience sample of 12 colleagues from two research institutions rated cessation tips from a Nicotine Anonymous pamphlet on two dimensions: whether the tip was primarily cognitive or behavioral (cognitive, behavioral, not sure) and whether the tip was consistent with current cognitive-behavioral cessation programs (consistent, not consistent, not sure). The raters were research psychologists, health educators and nurses with experience in developing, evaluating, and/or implementing cessation programs.

Left

1. Effectiveness of smoking cessation self-help materials in a lung cancer screening population
2. Humphreys., Keith (2004). "Chapter 2: An international tour of addiction-related mutual-help organizations". Circles of Recovery: Self-Help Organizations for Addictions. Cambridge University Press. pp. 77–78. ISBN 0521792770. OCLC 57190081.

Literature

Nicotine Anonymous Materials Besides Nicotine Anonymous: The Book, the organization provides a number of free (brief) pamphlets that describe the program or provide information helpful for quitting. The free pamphlets include A Smoker's View of the 12-Steps, Introducing Nicotine Anonymous to the Medical Profession, Introducing Nicotine Anonymous, To the Newcomers and Sponsorship in Nicotine Anonymous, and The Serenity Prayer for Smokers. One pamphlet, Tips for Gaining Freedom from Nicotine, contains 40 briefly described tips, many of which are quite consistent with current cognitive-behavioral treatment programs. The convenience sample of 12 colleagues displayed strong agreement categorizing 18 items as cognitive and 16 as behavioral, and 22 tips (55%) were seen by the majority of the raters to be consistent with typical cognitive-behavioral programs. Behavioral tips were more likely to be seen as consistent with cognitive-behavioral principles (13 of 16) than were cognitive items (6 of 18). Tips seen as consistent with cognitive behavioral principles included set a date, make a commitment, plan to do things that will keep your mind off smoking, have something to fidget with, have something to put in your mouth, frequently give yourself a pat on the back, and remember that the discomfort you experience in the first 2 weeks will definitely come to an end. Tips rated as inconsistent tended to be exhortational, spiritual in nature, or both, for example, "Remember, every minute you were sucking on cigarettes they were sucking on you," or "Don't say, Til take my chances' and continue to smoke. They are not ours to take ... that is up to God."

pamphlets that describe the program or provide information helpful for quitting. The free pamphlets include A Smoker's View of the 12-Steps, Introducing Nicotine Anonymous to the Medical Profession, Introducing Nicotine Anonymous, To the Newcomers and Sponsorship in Nicotine Anonymous, and The Serenity Prayer for Smokers.

One pamphlet, Tips for Gaining Freedom from Nicotine, contains 40 briefly described tips, many of which are quite consistent with current cognitive-behavioral treatment programs. The convenience sample of 12 colleagues displayed strong agreement categorizing 18 items as cognitive and 16 as behavioral, and 22 tips (55%) were seen by the majority of the raters to be consistent with typical cognitive-behavioral programs. Behavioral tips were more likely to be seen as consistent with cognitive-behavioral principles (13 of 16) than were cognitive items (6 of 18). Tips seen as consistent with cognitive behavioral principles included set a date, make a commitment, plan to do things that will keep your mind off smoking, have something to fidget with, have something to put in your mouth, frequently give yourself a pat on the back, and remember that the discomfort you experience in the first 2 weeks will definitely come to an end. Tips rated as inconsistent tended to be exhortational, spiritual in nature, or both, for example, "Remember, every minute you were sucking on cigarettes they were sucking on you," or "Don't say, Til take my chances' and continue to smoke. They are not ours to take ... that is up to God."

• Nicotine Anonymous World Services (2004). Nicotine Anonymous: The Book (3rd Edition ed.). Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 097701150X. OCLC 32687553. {{cite book}}: |edition= has extra text (help); Unknown parameter |month= ignored (help)
• Nicotine Anonymous World Services (2003). Our Path to Freedom Twelve Stories of Recovery. Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 0977011518. {{cite book}}: Unknown parameter |month= ignored (help)
• Nicotine Anonymous World Services (2004). 90 Days, 90 Ways. Huntington Beach, CA: Nicotine Anonymous World Services. ISBN 0977011526. {{cite book}}: Unknown parameter |month= ignored (help)

See also

Smoking Nicotine American Lung Association American Cancer Society American Heart Association

External Links

• Smokers Anonymous