Tobacco, cocaine, and heroin: Craving and use during daily life

Abstract

Background: Relationships among tobacco smoking, tobacco craving, and other drug use and craving may have treatment implications in polydrug-dependent individuals.

Methods: We conducted the first ecological momentary assessment (EMA) study to investigate how smoking is related to other drug use and craving during daily life. For up to 20 weeks, 106 methadone-maintained outpatients carried PalmPilots (PDAs). They reported their craving, mood, behaviors, environment, and cigarette-smoking status in 2 to 5 random-prompt entries/day and initiated PDA entries when they used cocaine or heroin or had a discrete episode of craving for cocaine or heroin.

Results: Smoking frequency increased linearly with random-prompt ratings of tobacco craving, cocaine craving, and craving for both cocaine and heroin. Smoking frequency was greater during discrete episodes of cocaine use and craving than during random-prompt reports of low craving for cocaine. This pattern was also significant for dual cocaine and heroin use and craving. Smoking and tobacco craving were each considerably reduced during periods of urine-verified abstinence from cocaine, and there was a (nonsignificant) tendency for morning smoking to be especially reduced during those periods.

Conclusions: This EMA study confirms that smoking and tobacco craving are strongly associated with the use of and craving for cocaine and heroin. Together with prior findings, our data suggest that tobacco and cocaine may each increase craving for (and likelihood of continued use of) themselves and each other. Treatment for tobacco dependence should probably be offered concurrently with (rather than only after) initiation of treatment for other substance-use disorders.

Fig. 1

Percentage of random prompts at which participants reported smoking tobacco, by degree of reported tobacco craving. The denominators for the four columns are: 8,812 (craving rated 0); 7,245 (craving rated 1); 5,657 (craving rated 2); and 3,110 (craving rated 3). The bars show raw percentages, whereas the statistical results are adjusted for sex, race, age, and location. The pattern of covariate-adjusted percentages (not shown) was similar to the pattern of raw percentages.

Fig. 2

Four left columns: Percentage of random prompts at which participants reported smoking tobacco, by degree of reported cocaine craving. Two right columns: Percentage of event-contingent prompts at which participants reported smoking tobacco. The denominators for the six bars were: 12,569 (cocaine craving rated 0); 8,125 (cocaine craving rated 1); 2,373 (cocaine craving rated 2); 1,792 (cocaine craving rated 3); 597 (event-contingent cocaine-craving entry); 665 (event-contingent cocaine-use entry). The bars show raw percentages, whereas the statistical results are adjusted for sex, race, age, and location. The pattern of covariate-adjusted percentages (not shown) was similar to the pattern of raw percentages.

Fig. 3

Four left columns: Percentage of random prompts at which participants reported smoking tobacco, by degree of reported heroin craving. Two right columns: Percentage of event-contingent prompts at which participants reported smoking tobacco. The denominators for the six bars were: 15,098 (heroin craving rated 0); 7,647 (heroin craving rated 1); 966 (heroin craving rated 2); 1,103 (heroin craving rated 3); 257 (event-contingent heroin-craving entry); 60 (event-contingent heroin-use entry). The bars show raw percentages, whereas the statistical results are adjusted for sex, race, age, and location. The pattern of covariate-adjusted percentages (not shown) was similar to the pattern of raw percentages.

Fig. 4

Four left columns: Percentage of random prompts at which participants reported smoking tobacco, by degree of reported dual craving for heroin and cocaine. For dual-craving data, we used only random-prompt reports in which craving ratings for cocaine and heroin were identical (69.4% of the 27,760 random-prompt reports). Two right columns: Percentage of event-contingent prompts at which participants reported smoking tobacco. The denominators for the six bars were: 11,782 (dual craving rated 0); 6,270 (dual craving rated 1); 505 (dual craving rated 2); 696 (dual craving rated 3); 605 (event-contingent dual-craving entry); 229 (event-contingent dual-use entry). The bars show raw percentages, whereas the statistical results are adjusted for sex, race, age, and location. The pattern of covariate-adjusted percentages (not shown) was similar to the pattern of raw percentages.

Fig. 5

Time course of tobacco craving and smoking during periods of 1 or more weeks of cocaine abstinence or cocaine use across the day from 6 AM to 12 PM. (a) Data shown are mean ratings on a four-point (0 to 3) scale. Brackets indicate SEM. (b) Data shown are percentages. Abstinence/use was a time-varying predictor; thus, 34 participants contributed data to both the “abstinence” line and the “use” line. For cocaine abstinence, the median number of datapoints per symbol is 496 (range 24 to 789; all values over 100 from 8:00 am through 9:00 pm); for cocaine use, the median number of datapoints per symbol is 1,058 (range 63 to 1,579; all values over 100 from 7:00 am onward). *Significant difference between use and abstinence at this time point in Bonferroni-corrected post hoc F tests (“slice” option in SAS).