Quashing alcohol, nicotine addictions at same time boosts chance of longer-term sobriety, studies suggest.

Overcoming alcoholism is tough enough. That’s one reason many alcoholics who smoke continue to light up even while they’re in recovery from alcohol dependency.

But new research suggests that tackling both addictions simultaneously may offer the best chance of success.

Recovering alcoholics often admit they’re using nicotine as a drug, says Dr. Michael M. Miller, president of the American Society of Addiction Medicine.

“They can tell you, ‘I don’t want to quit (smoking), because it changes the way I feel. I use it to deal with stress,’ ” adds Miller, who’s also director of NewStart, a chemical dependency rehabilitation program at Meriter Hospital in Madison, Wis.

A study of alcoholics in treatment for their alcohol problems used brain scans to examine how performance on cognitive tests changes with abstinence from alcohol. Twenty-five alcoholics stopped drinking for six to nine months, but the 12 who smoked continued to smoke.

“We found that the smoking alcoholics over six to nine months of abstinence did not recover certain types of brain function as the nonsmoking alcoholics did,” says study author Dieter J. Meyerhoff, a professor of radiology at the University of California-San Francisco. Decision-making skills, thinking speed, 3-D visualization and short-term memory were affected, calling into question the prospects of long-term sobriety, he noted.

And while smoking and non-smoking alcoholics improved on several other cognitive tests, such as learning and remembering words, smokers’ brain function, in general, took longer to recover.

The findings were published in the journal Alcoholism: Clinical and Experimental Research.

Studies indicate that 60 percent to 75 percent of people in alcohol-treatment programs smoke cigarettes, and 40 percent to 50 percent are “heavy” smokers, consuming more than a pack a day.

Yet treatment for tobacco dependence is not routinely included in alcohol treatment programs, Boston University researchers reported recently in the journal Alcohol Research & Health, published by the U.S. National Institute on Alcohol Abuse and Alcoholism.

“I would say that over half of chemical dependency treatment agencies now talk about nicotine, encourage patients to stop (smoking) and provide them assistance to stop, such as with nicotine-replacement therapy or prescriptions for Zyban or Champix,” Miller says. “So that’s a tremendous advance.”

Oftentimes, though, smoking is excused. “What you don’t see,” Miller says, “is building nicotine into the treatment plan and considering tobacco use to be a relapse of addiction.”

The concern had been that addressing both dependencies concurrently would pose “too great a difficulty for the patient” and impede recovery from alcoholism, the Boston researchers noted. But studies now suggest that quitting smoking does not derail alcohol treatment – and may even improve the likelihood of longer-term sobriety, they said.

In fact, Miller says studies show that people in recovery for other addictions who delay smoking cessation can later relapse to their chemical dependency because of the stress of quitting smoking six to 18 months later.

“So stopping everything at once – getting all the psychological stress out of the way at once – is the best way to go, and also getting all the physical withdrawal syndromes out of the way at once is the best way to go,” he concluded.

“The alcoholics have shown that they are willing to change one behavior, namely excessive drinking,” he says. “If they are in that mind-set, it is a great opportunity for treatment specialists to also convince them of the negative effects of continued chronic smoking,” Meyerhoff said.

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ON THE WEB

www.aafp.org/af

980415a

980415c.html, the official Web site for the American Academy of Family Physicians, offers advice for recovering alcoholics on quitting smoking.

Suppose you’re a healthy, physically fit, nonsmoking male. Your risk of heart attack is already low. Would having a drink or two of alcohol a day provide any additional protective benefit?

A study by Harvard University researchers suggests the answer is yes. Even among men who are models of health, moderate drinking was associated with a lower risk of heart attack. Those who had one-half to two drinks a day had the lowest heart attack risk – 40 percent to 60 percent lower than healthy men who didn’t drink. And that was true no matter whether they were drinking beer, wine or liquor.

“These results tend to refute the oft-quoted hypothesis that lower coronary heart disease seen among moderate drinkers is due to their associated healthy lifestyle habits, and not to their alcohol consumption,” wrote Dr. R. Curtis Ellison, director of the Institute on Lifestyle and Health at Boston University School of Medicine, and co-author of a critique of the study.

In 2008, an estimated 770,000 people will suffer a heart attack, according to the American Heart Association.

Dozens of studies have linked moderate drinking and lower risk of heart disease. In a nod to that evidence, the AHA advises people who drink to do so in moderation – no more than two drinks a day for men and one drink a day for women.

What’s been less clear is whether people who exercise, abstain from smoking, maintain an optimal weight and adhere to an appropriate diet would see any benefit from drinking.

Using data from more than 50,000 health professionals, study author Dr. Kenneth J. Mukamal, assistant professor of medicine at Harvard Medical School, and his colleagues identified more than 8,800 men who were nonsmokers, ate a healthy diet, exercised at least 30 minutes a day and weren’t overweight. Over a 16-year period, 106 of the men had heart attacks, but those who had two drinks a day had the lowest risk for heart attack, while nondrinkers had the highest risk.

Several other recent studies have added to the evidence suggesting moderate alcohol intake complements a healthy lifestyle.

A recent British study identified moderate alcohol consumption among four healthy behaviors (including not smoking, exercising and eating five servings of fruits and vegetables a day) that added 14 years to life, compared with men and women who did not adopt these behaviors. And Danish researchers reported that both physical activity and moderate drinking have a protective effect on the heart and an additive benefit when combined as part of a healthy lifestyle.

There’s one glaring problem, though. None of the studies were “randomized controlled trials” – the gold standard of scientific research, whereby people are randomly assigned to an intervention, such as exercising or consuming alcohol.

There are lots of observational data to support moderate drinking, said Dr. Robert A. Vogel, professor of medicine and director of clinical vascular biology at the University of Maryland School of Medicine. “However, we do not consider alcohol a validly tested drug because to do that you would have to randomize people for years with alcohol or not – and that’s not a study that can be done,” he said.

Vogel said he enjoys a daily glass of wine as part of a healthy lifestyle and tells patients who do the same that it’s “a reasonable thing to do.” Many doctors, though, tend to shy away from recommending alcohol to their patients. Instead, they have emphasized other lifestyle modifications, including diet and exercise.

“Clinicians are very resistant to taking alcohol out of the ‘alcoholism’ box and asking what its effects might be at more typical levels of intake,” Mukamal said. “Even if clinicians don’t believe there are benefits to alcohol, and I think that’s a reasonable concern since we don’t have randomized trails, they should at least be discussing it, but I don’t think that’s happening.”

Ellison agrees. For middle-aged and older men and postmenopausal women who don’t have ethical, religious or health reasons for avoiding alcohol (such as pregnancy or diseases), “physicians should at least inform them that the scientific data currently available strongly suggest that a small amount of alcohol on a regular basis may lower their risk of heart disease, stroke, diabetes, dementia, and even total mortality,” he said.

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ON THE WEB

American Heart Association: americanheart.org

Postpartum depression has gotten a softer face in recent years as celebrity mothers, such as Brooke Shields, who’ve experienced its devastating symptoms, have begun to share their personal stories.

Still hidden, though, are the identities of new fathers who have suffered in silence all these years.

Almost as many men as women suffer from this type of depression, according to researchers who examined data from more than 5,000 two-parent families. In all, about 14 percent of mothers and 10 percent of fathers showed signs of moderate or severe postpartum depression, according to the study, first reported in the August 2006 issue of the journal Pediatrics.

“The long-standing belief of many people, including physicians, has been that postpartum depression is due to hormone changes in women that take place after childbirth,” said study leader James F. Paulson, an assistant professor of pediatrics, behavioral research and community health at Eastern Virginia Medical School’s Center for Pediatric Research in Norfolk. “Obviously, fathers wouldn’t be susceptible to changes of this nature and, probably because of this, haven’t been a focus of study.”

Janice Goodman, a psychiatric clinical nurse specialist and assistant professor at the MGH Institute of Health Professions, an affiliate of Massachusetts General Hospital in Boston, agrees that hormonal changes aren’t the only plausible explanation.

“In both men and women, the huge life changes that go along with having a baby can contribute to depression,” she said.

Postpartum depression can begin anytime after childbirth and can last up to a year, according to Mental Health America, formerly the National Mental Health Association. Symptoms often mirror those of any clinical depression, such as sadness, fatigue and hopelessness. A sufferer may experience drastic changes in mood and appetite, excessive preoccupation with a child’s health, or intrusive thoughts of harming the baby.

While research suggests that hormonal changes may contribute to the onset of postpartum depression in women, “no definitive hormonal cause” has been identified, Paulson pointed out. Other factors suspected to play a role include history of depression, fatigue, marital discord, social support and financial support.

“Factors of this nature certainly can affect fathers, and they probably do in many families,” he added.

For the study, parents completed questionnaires and were interviewed to determine whether they showed symptoms of depression. Researchers also probed parent-child interactions, such as reading, telling stories, and singing songs – acts considered critically important for positive child development.

Depression in either parent was associated with reduced interaction, Paulson noted, and “fathers with greater levels of depression interacted with their child less.”

Goodman said the research highlights a link between maternal and paternal postpartum depression, or PPD, “such that men whose partners are distressed are at significantly higher risk of experiencing PPD themselves.”

Yet postpartum paternal depression typically isn’t on clinicians’ radar, she conceded, and men often have less contact with health-care providers than women do.

However reluctant they may be to seek help, it’s important for new dads who are experiencing symptoms of depression to see their primary-care provider or a mental-health specialist for evaluation and treatment, Goodman said.

“One important implication for clinicians is, if a woman is identified as depressed during the postpartum period, to ask the father how he’s doing and to screen for depression in him,” she added.

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On the Web:

www.nmha.org, Mental Health America has more information on postpartum depression.

To arrest rising health-care costs, a growing number of U.S. employers are expanding workplace “wellness” initiatives. Providing workers with tools and incentives to improve their health, the thinking goes, will reduce medical-care costs and boost worker productivity.

Experts say it’s a trend that bodes well for employees who are motivated to lose weight, quit smoking, manage a chronic condition or just stay fit.

“Pretty clearly, employers have realized that if they’re going to manage benefit costs and manage work loss, they need to get at the underlying health drivers of that – employee health – and get at the root causes of health-care utilization and health-care expenditures,” said Bruce Kelley, practice leader for data services in the Minneapolis office of Watson Wyatt Worldwide, a human resources consulting firm.

According to Kelley, employers have been investing much more heavily in wellness services in the past few years. “I’ve been consulting in this area for 20 years,” he noted, “and I’ve never seen as much activity among employers as I’ve seen just in the last few years.”

Wellness is a broad term that describes the panoply of health-management services that companies offer, from onsite fitness centers and smoking-cessation classes to health-risk appraisals and disease-management programs.

Surveys show that more large employers are offering programs to improve employee health and productivity. Seventy-five percent offered a “health promotion” program in 2005 or 2006, up from 56 percent in 2003, according to survey results released December 2005 by Watson Wyatt and the National Business Group on Health.

Nearly 3 out of 4 employers (72 percent) are sponsoring health-risk appraisals to measure individual employees’ health risks and behaviors. And 40 percent are engaging “personal health coaches,” health professionals who can help, say, an employee with diabetes manage their diet, exercise and drug regimens.

At the same time, corporate America and public health leaders are grappling to understand which particular interventions or combinations of programs and incentives yield the greatest return on investment.

“There has not been a tremendous amount of high quality research in this area,” said Doug Evans, director of the Center for Health Promotion Research at RTI International, a nonprofit research institute based in Research Triangle Park, N.C.

But there are a number of efforts under way to learn what works. The U.S. Centers for Disease Control and Prevention, for one, is sponsoring a series of studies to evaluate worksite efforts to prevent and control obesity.

A study in the September/October 2005 issue of the American Journal of Health Promotion reported CDC and RTI researchers found that obesity boosts employers’ costs, including medical expenditures and absenteeism, by $460 to $2,500 per obese employee per year. They put the cost of obesity at a firm with 1,000 employees at about $285,000 per year.

In March, the National Business Group on Health issued 10 recommendations for promoting prevention in the workplace. Overall, it concluded that without the support of top-level management, companies cannot convey “the importance to employees of caring for themselves.”

Some employers are using incentives to get workers on the wellness bandwagon. You might qualify for a lower health insurance premium, say, if you stop smoking, or you could earn a $25 gift certificate for completing a health-risk appraisal.

The use of incentives will continue, Evans predicted. However, he believes employers must do a better job of promoting the benefits of health, much as anti-tobacco advocates did by portraying a nonsmoking lifestyle as cool, hip and fun.

“Maybe that kind of technique can be effective in obesity,” he said. “Can you make it cool to be healthy weight and not to be fat?”