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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
Reckitt Benckiser
Pfizer
Research Support
SAMHSA
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
6
It’s the Smoke that Kills
Cigarette smoke > 4000
compounds
Acetone, Cyanide, Carbon Monoxide,
Formaldehyde
> 60 Carcinogens
Benzene, Nitrosamines
(CDC
2003)
9
Nicotine Safety
Smokers 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
10
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
11
Nicotine
Possible therapeutic effects:
Alzheimer's
Attention deficit disorder
Autism
Schizophrenia
Ulcerative colitis
12
Tobacco Use Disorder: DSM5
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: DSM5
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: DSM5
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.
Nicotine Withdrawal
Depressed mood
Insomnia
Irritability, frustration or anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
16
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
Screening : Five As
Ask about smoking
Advise to quit
Assess about willingness to quit
Assist with quitting
Arrange help to quit
Medications
Group support
33
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)
34
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
2130
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
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
36
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
Effective Treatments
Pharmacological
Reduce or eliminate withdrawal
Block reinforcing effects of nicotine
Manage negative mood states
45
FDA-Approved Medications
Drug of Abuse
Brand Name
Generic Name
Nicotine
Nicotine
Replacement
Therapies
Chantix
Patches,
Lozenge,
Inhalers,
Gums
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
50
Additional Resources
• California Tobacco Control Program
– dhs.ca.gov/tobacco
• Nobutts.org
• Tobaccofree.ucla.edu
Contact Information
Timothy Fong MD
UCLA Gambling Studies Program
310-825-1479 (office)
[email protected]
uclagamblingprogram.org