Gambling and Tobacco:Peas in a Pod

Timothy W. Fong MD

UCLA Gambling Studies Program

UC Tobacco Cessation Network

Problem Gambling Training Summit

March 3, 2014

Financial Disclosures

Speaker Bureau Research Support

Reckitt Benckiser SAMHSA

Pfizer OPG (California)

Annenberg Foundation

Tulare County

Bridges to Recovery

Smoking in California

Smoking in California

• First state to enact– Tobacco control program (1988) – Smoke-Free workplace (1994) – Indoor smoking bans

• Current smoking prevalence for adults

13.3% (2008)

22.7% (1988)

Smoking in California

• 972 million packs sold per year (2011)

• 34 packs per adult per capita per year (2011)

• 2nd lowest state consumption of cigarettes (Utah #1)

• #1 source of litter

Smoking is the #1 Preventable Cause of Death

• ~50% of smokers try to quit/ year

• Advice from MD ↑ quitting

• Double success with treatment

• But….many providers don’t focus on smoking cessation

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9

It’s the Smoke that Kills

Cigarette smoke > 4000 compounds Acetone, Cyanide, Carbon Monoxide, Formaldehyde

> 60 CarcinogensBenzene, Nitrosamines

(CDC 2003)

10

Nicotine SafetySmokers misinformed about

safety/efficacy of nicotine Not a carcinogen Not a significant risk factor for

cardiovascular events

Risk-benefit ratio supports nicotine medications over using tobacco

11

Nicotine Pharmacology

Pharmacology depends on delivery route

Reaches brain in 10 sec

Arterial levels 6-10x higher than venous

Half-life 2 hours

Metabolized to cotinine in liver

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Nicotine Possible therapeutic effects:

Alzheimer's

Attention deficit disorder

Autism

Schizophrenia

Ulcerative colitis

Tobacco Use Disorder: DSM-5

1.______ is often taken in larger amounts or over a longer period than was intended.

2.There is a persistent desire or unsuccessful efforts to cut down or control _____ use.

3.A great deal of time is spent in activities necessary to obtain __________ , or recover from its effects.

4.Craving, or a strong desire or urge to use _____________

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).  American Psychiatric Association. All rights reserved. 

Tobacco Use Disorder: DSM-5

5.Recurrent ______ use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued ______ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because of ______ use.

8. Recurrent ______ use in situations in which it is physically hazardous.

9. ______ use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).  American Psychiatric Association. All rights reserved. 

Tobacco Use Disorder: DSM-5

10. Tolerance, as defined by either of the following:

A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

A markedly diminished effect with continued use of the same amount of ______

11. Withdrawal, as manifested by either of the following:

The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal).

______ is taken to relieve or avoid withdrawal symptoms.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).  American Psychiatric Association. All rights reserved. 

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Nicotine Withdrawal

Depressed moodInsomniaIrritability, frustration or angerAnxietyDifficulty concentratingRestlessnessDecreased heart rateIncreased appetite or weight gain

How are smoking and gambling related?

Gambling and Smoking

Smoking and Casinos

• Smoke-Free in Card Clubs, Racetracks• Not Smoke-Free in Tribal Casinos

• Impact– Second-hand smoke (up 9x higher than

outside)– Most casino patrons don’t smoke– Neglible impact on revenue

Increased Smoking Rates in PG

• 62% of treatment seeking gamblers in Connecticut

• 69% in Minnesota smoked – much higher than general population 25%

• (Petry & Oricken 2002, Stinchfield and Winters 1996)

Smoking and Gambling

• Gamblers who smoked daily gambled more days and spent more money than non-daily smokers.

• They craved gambling more and had lower perceived control over gambling (Petry & Oricken 2002)

Smoking and Gambling: Severity

• Daily tobacco use was reported in 244 (63.4%) subjects.

• Tobacco users presented with significantly more severe gambling and mental health symptoms at treatment intake.

• Similar rates of treatment completion and treatment outcomes as nonusers.

• (Odlaug 2013)

CPGTSP 2012-2013

CPGTSP 12-13: Affected Individuals

Biological Explanations

• Nicotine and gambling preferentially release dopamine

• Similar brain areas impacted

• Genetic predisposition

• Priming from alcohol and sex cues associated with one another

Smoking and Gambling: How and Why

• Nicotine may raise the “hedonic” value of gambling

• Nicotine may raise the “cue reactivity” of things surrounding gambling

• Nicotine may increase attention and focus on gambling (“stay in action”)

Psychological Explanations

• Smoking eases stress of gambling

• Maximizes the “escape” and “action” of gambling

• Activity justified by gambler (e.g. “might as well”)

• High impulsivity

• Psychological myopia

Sociological Explanations

• Access

• Availability

• Tolerability

• Cultural portrayal

• Peer pressure

• Learned co-occurring activities

Treatment Approaches For Smoking Cessation

Screening, Assessment and Treatment

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Screening : Five As

Ask about smokingAdvise to quit Assess about willingness to quit Assist with quitting Arrange help to quit

MedicationsGroup support

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Heaviness of Smoking Index= Measure of Dependence

Number of cigarettes per day (cpd)

AM Time to first cigarette (TTFC)≤ 30 minutes = moderate

≤ 5 minutes = severe

(Heatherton 1989)

Fagerstrom Test For Nicotine Dependence

0 1 2 3

How soon after you wake up do you smoke your first cigarette?

>1 hr 30-60 min

6-30 min

Within 5 min

Do you find it difficult to refrain from smoking in places where it is forbidden?

No Yes

Which cigarette would you hate most to give up?

All 1st one

How many cigarettes / day do you smoke?

<10 11-20 21-30 30 +

Do you smoke more frequently during the first hours of waking than during the rest of the day?

No Yes

Do you smoke if you are so ill that you are in bed most of the day?

No Yes

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Hard to Quit Without Treatment

• 70% of smokers want to quit

• Few quit without treatment

• < 1/3 remain abstinent for 2 days

• < 5% ultimately successful per quit attempt

Smoking Cessation Results: During Addictions Treatment

or Recovery

Systematic review of 17 studies

Smokers with current and past alcohol

problems:

As able to quit smoking as individuals without alcohol problems

Hughes & Kalman 2006

Important to Recover Concurrently

• Stopping smoking at the same time as other addictions:

• Individuals in addictions treatment was associated with 25 percent increased abstinence from alcohol and illicit drugs six months or longer after treatment.

• (Prochaska 2008)

Barriers to treatment

• High prevalence of smokers in GA

• Ongoing smokers around patient

• Lack of motivation

• False belief that quitting all addictions simultaneously is “too difficult”

• Resentment at giving up all “pleasures”

• Provider fatalism

Impact of treatment

Brief physician advice ↑ quitting 10% quit rates with < 3 minutes 20% quit rates >10 minutes

Tobacco dependence = chronic condition< 25% successful on first attempt> 8 quit attempts before successful

The Key To Smoking Cessation

• The combination of medication and counseling is more effective for smoking cessation than either medication or counseling alone

• Medication and counseling = success

Effective treatments

• Psychosocial Treatments– Brief clinical interventions

• Discussion with health care provider

– Counseling • Nicotine anonymous groups

– Behavioral cessation therapies • Freedom from Smoking

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Effective Treatments

Pharmacological

Reduce or eliminate withdrawal

Block reinforcing effects of nicotine

Manage negative mood states

FDA-Approved Medications

Drug of Abuse Brand Name Generic Name

Nicotine Nicotine Replacement

Therapies

Patches, Lozenge, Inhalers,

Gums

Chantix Varenicline

Zyban Bupropion

California Smokers’ Helpline : UCSD

1-800-NO-BUTTS

– M-F 7am-9pm;

– Sat/Sun 9am-5pm

1-800-NO-BUTTS

• Self-help materials, referral to local programs, and one-on-one, telephone counseling to quit smoking.– 30-40 minute initial counseling– Up to 6 follow-up sessions

• Doubles a smoker’s chances of successfully quitting.

• 6 languages (English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese)

Future Directions

• Tobacco Free IOP and Residential Treatments Programs

• Increased reimbursement for achieving tobacco-free patients (monitored)

• Increased reimbursements for screening and counseling

• Combined groups for Tob + PG• Gambling industry involvement

Conclusions

• It’s the smoke that kills – not the nicotine

• All practitioners should screen and arrange for smoking cessation

• Combo treatments work

• Gambling and smoking occurring commonly and rarely treated together

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Additional Resources

• California Tobacco Control Program– dhs.ca.gov/tobacco

• Nobutts.org

• Tobaccofree.ucla.edu

Contact InformationTimothy Fong MD

UCLA Gambling Studies Program

310-825-1479 (office)tfong@mednet.ucla.edu

uclagamblingprogram.org