Journal of Psychoactive Drugs
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
Nicotine Dependence and Alcoholism Epidemiology and Treatment Janet Kay Bobo To cite this article: Janet Kay Bobo (1992) Nicotine Dependence and Alcoholism Epidemiology and Treatment, Journal of Psychoactive Drugs, 24:2, 123-129, DOI: 10.1080/02791072.1992.10471633 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471633
Published online: 20 Jan 2012.
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Citing articles: 29 View citing articles
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Date: 07 November 2015, At: 06:27
Nicotine Dependence and
Downloaded by [Australian National University] at 06:27 07 November 2015
Alcoholism Epidemiology and Treatment JANET KAY BOBO, M.S.W.* Abstract-Nicotine dependence in alcohol-involved adults is a long-ignored treatment problem. The absence of its discussion in the literature is difficult to defend in light of medical and epidemiological data on the cost and prevalence of this dual addiction. Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. There is a crucial need to educate treatment professionals and their clients about the additional health risks associated with joint nicotine dependence and alcoholism. Historically, certain barriers to active intervention have existed in drug abuse treatment facilities, including (1) concerns that urging clients to quit smoking might have an adverse effect on their maintenance of sobriety, (2) a tendency to minimize the strength and severity of nicotine addiction, (3) a lack of informative data on how best to treat smoking in recovering alcoholics, and (4) financial issues related to marketing and insurance compensation. Recent data obtained from recovering alcoholics who have tried to quit smoking and anecdotal reports from alcoholism treatment centers that have begun addressing nicotine addiction are now challenging thesebarriers. Education,role modeling, environmental control, and development of staff expertise can be incorporated into standard alcoholism treatment programs to jointly treat these paired addictions. Keywords-alcohol-nicotine epidemiology, alcohol-nicotine health risks, alcohol-nicotine treatment
Twenty-five years ago the popularity of smoking among American males began to diminish. Over 50% of all adult men were smokers in 1965, but the figure had dropped to 33.5% by 1985 (Fioreetal.1989; Warner 1989).Tobacco's popularity continued to rise among women for several years after the Surgeon General's 1964 report (U.S. Department of Health, Education and Welfare 1964), but has, at least since 1974, declined steadily. In 1985, the prevalence of smoking among adult females was estimated to be 27.6%. Preliminary analyses of responses to the 1987 National Health Interview Survey suggest even lower percentages of 31.7% for men and 26.8% for women (Fiore et at. 1989). These data are in striking contrast to those obtained
from samples ofalcohol-involved adults. Dreher and Fraser (1967) collected tobacco use information on 103 alcoholic outpatients in 1965 and noted that 92.7% of the males and 90.5% of the females were smokers. Only two studies addressing nicotine dependence in alcoholics were reported in the 1970s (Bobo & Gilchrist 1983). Both studies focused exclusively on men and both showed even higher rates of 97% and 94% (Ayers, Ruff & Templer 1976; Walton 1972). In 1981, Ashley and colleagues reviewed 1,001 inpatient treatment center admissions occurring between 1967 and 1969, and found that 92.1 % of the males and 95.2% of the females were smokers (Ashley et al. 1981). A similar survey conducted on 1979-80 admissions showed somewhat lower estimates of86% and 82% for men and women, respectively (Kozlowski, Jelinek & Pope 1986). The most recently reported estimate, derived from a sample of male
-Research scientist, Department of Epidemiology, SC-36, University of Washington, Seattle, Washington 98195.
Journal
of Psychoactive Drugs
123
Vol. 24(2), Apr-Jun 1992
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use of the two substances. The data reported by Blot and colleagues are iIlustrative. They identified all new, reported cases ofcertain types of oral/pharyngeal cancers in adult men and women in four regions of the United States in 1984-85. After obtaining alcohol and tobacco use histories from these 1,114 patients, they collected similar data from 1,268 age, race, and gender-matched individuals who had been randomly selected from the communities of the oral cancer cases. Their findings for males and females were quite similar, but results for the two groups were reported separately. Only the results for men, who constituted 68.4% of the sample, will be reviewed here . Among nonsmokers, it was found that men who were heavy drinkers (averaging 30 or more drinks per week) were 5.8 times more likely to develop an oral cancer than those who drank less than one alcoholic drink per week. Among nondrinkers, it was observed that men who were heavy smokers (two or more packs of cigarettes a day) were 7.4 times more likely to develop a cancer than those who were nonsmokers. Among the 169 men who had a history of heavy drinking and heavy smoking, the risk of disease was 37.7 times as great as that observed among those who drank rarely and did not smoke. On a more positive note, these researchers also found a sharp drop in risk associated with smoking cessation. After controlling for alcohol use history, they found only a 10% increase in risk (an odds ratio of 1.1 among former smokers who had not smoked for 10 years or more . They concluded that smoking must thus affect a relatively late stage in the process of oropharyngeal carcinogenesis. The implications of these findings to the recovering alcoholic who continues to smoke are clear. Yet, most chemical dependence treatment centers in the United States skirt or completely ignore the issue of nicotine addiction. In a 1983 survey of all licensed, inpatient alcoholism treatment centers (ATCs) in Washington state, no facility reported offering treatment of nicotine dependence concurrent with or subsequent to alcoholism treatment, even though 27% ofthe responding staff felt that such a program should be available for their clients (Bobo & Gilchrist 1983). A recent survey of 227 chemical dependence treatment facilities in Minnesota yielded similar results. Although 72.2% of the respondents felt that smoking should be addressed, only 11.2% of the programs included treatment of nicotine dependence in 1988 (Knapp 1989).
inpatient alcoholics in California, is depressingly consistent with the earlier studies: 90% of the surveyed alcoholics were found to be current smokers (Burling & Ziff 1988). Smoking also tends to be highly correlated with drinking among nonalcoholics. Many studies have found higher rates of smoking among heavy social drinkers compared to light or nondrinkers (Carmody et al. 1985; Istvan & Matarazzo 1984; Craig & VanNatta 1977). Why alcohol-involved adults are so much more likely to smoke remains unclear. Various theories have been proposed, including the presence ofan underlying addictive personality; the existence ofa stronger oral drive in alcoholics than nonalcoholics; a tendency for increased socialization in drinkers, which places them more frequently in the presence of other smokers; and the existence of biologic interactions associated with concurrent alcohol-tobacco consumption (McCoy & Napier 1986; Walton 1972). The evidence supporting each of these possibilities is fragmentary and will not be reviewed here. The objective of the present article is to highlight the barriers that continue to block widespread treatment of nicotine dependence in recovering alcoholics. The alcoholism treatment field, while progressive in many arenas, has failed to fully mirror the growing rejection of smok ing so evident in the general population. Chemical dependence treatment counselors need to be aware of these barriers and, equally important, of the work that is being done to surmountthem. To limit the scope of this review, two assumptions are made . The first is that alcoholics, recovering and otherwi se, continue to smoke largely because they, like heavy smokers in general, are addicted to nicotine (Kozlowski et al. 1989; U.S. Department of Health and Human Services 1989; Henningfield & Nemeth-Coslett 1988). The second assumption is that the health problems associated with smoking equal or exceed those associated with alcoholism. Because individuals who both drink and smoke face health risks even greater than those generally associated with smoking alone, and because these additional health risks are not widely appreciated, the synergistic effects of such paired consumption will be briefly reviewed first.
HEALTH EFFECTS OF SMOKING IN ALCOHOLICS The American Cancer Society (1988) has estimated that in 1987 alone there were at least 30,000 new cases of oral cancer and 9,000 deaths associated with such malignancies in the United States. Recent epidemiologic data suggest that the majority of those oral and pharyngeal cancers (80% in males, 61 % in females) were attributable to alcohol/tobacco consumption (Blot et al. 1988; Tuyns et aI. 1988; Flanders & Rothman 1982; Noble 1978). These high attributable risks reflect the multiplicative, or synergistic, increase in rates associated with paired, rather than isolated, Journal of Psychoacti ve Dru gs
BARRIERS TO TREATMENT OF NICOTiNE DEPENDENCE IN ALCOHOLICS Historically, four barriers have tended to limit opportunities for direct treatment of nicotine dependence in recovering alcoholics. 124
Vol. 24 (2). Apr-Juri 1992
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desire to quit smoking was obtained. (Alcoholic respondents may have had higher rates of smoking simply because they had made fewer serious attempts to quit.) When asked directly about the perceived difficulLy of quitting smoking in alcoholics compared to nonalcoholics, the counselors were about equally divided between those who felt it was harder for alcoholics to quit (46%) and those who disagreed or were not sure (54%) . "The absence of an informative body of literature is of concern because there are at least three key questions that consistently arise. Specifically, will asking an alcoholic client to quit smoking have an adverse effect on his or her ability to remain sober? If not, when should clients first be urged to quit smoking? And finally, what treatment techniques are most likely to be effective? Before moving on to the fourth barrier to treatment, the two studies that have been reported to date will be reviewed briefly. Effectofsmokingcessationonsobriety. Miller, Hedrick and Taylor's published results (1983) of a two-year followup study of 93 graduates of a behavioral self-control intervention focused on the reduction of alcohol consumption. For 39 of the participants, they obtained data on tobacco use at pretest and at six-month follow-up . They found that among clients who started out as smokers but had quit smoking by the six-month interview, 100% were successfully controlling their drinking. By contrast, among the individuals who were not smoking at pretest but were at follow -up, none showed acceptable control of their drink ing.No data were presented for participants whose smoking status remained unchanged from pretest to follow-up. Most chemical dependence treatment units in the United States employ a treatment methodology based on total abstinence rather than on control of drinking. ATC counselors have expressed concern about the appropriateness of generalizing findings from the latter model to the former . At best, these data suggest that in one sample of problem drinkers, smoking cessation apparently had no negative effect on efforts to remain sober. More direct evidence comes from a study that interviewed 73 recovering male alcoholics who had made at least one serious attempt to quit smoking since diseharge from an intensive, inpatient alcohol treatment program (Bobo et al. 1987; Bobo et aI. 1986). Self-selected respondents gave detailed data on their alcohol and tobacco use histories, and completed the legal, work, and social problems subscale of the Michigan Alcoholism Screening Test (Hedlund & Vieweg 1984; Gibbs 1983; Skinner 1982), and answered a series of open-ended questions concerning the effect of their smoking cessation attempt on the maintenance of sobriety. To insure the accuracy of the self-report data, participants provided names, addresses, and phone numbers of "verifiers" who could corroborate their responses. Verifiers were contacted for a randomly-selected 12% of the sample, and, in all cases, they fully substantiated
Resistance Explicit resistance to such treatment is often voiced by ATC staff who fear that the stress of trying to quit smoking might jeopardize the tenuous process of recovery in some of their clients. Twenty-three percent of 311 alcoholism treatment professionals responding to a survey in Washington state (Bobo & Gilchrist 1983) indicated they would "never" favor urging an alcoholic client who smokes to quit smoking, even five years after the onset of sobriety; and 46 % reported that they would never personally encourage such cessation. In that sample, reported attitudes and behaviors were strongly associated with the personal tobacco and alcohol use histories of the respondents. Those who selfidentified as recovering alcoholics who continued to smoke were significantly more likely to oppose urging tobacco cessation attempts than were those who were neither regular smokers nor former drinkers. Minimizing the Sequelae The chemicaldependence treatmen tindustry has tended to regard nicotine use as less difficult to control and less serious in its sequelae than alcoholism and other so-called hard drug addictions. A considerable literature exists on the epidemiology and treatment of the multiple drug user, but tobacco use is rarely considered as a part of the syndrome (Battjes 1988). Kozlowski and colleagues (1989) recently reported results of a survey that asked persons seeking treatment for alcohol or other drug dependence to rate the difficulty of giving up smoking in comparison to the problem substance for which they were seeking treatment. Seventy-four percent said that cigarettes would be at least as difficult to quit using as the substance for which they were being treated. These data, in conjunction with those presented in the Surgeon General's recent report on the health consequences of nicotine addiction (U.S. Depart ment of Health and Human Services 1988), should help leverage a shift in thinking toward a more realistic appraisal of nicotine's potency. Lack of Literature The paucity ofliterature on the treatment of smoking in alcoholics creates a third barrier. A thorough review of the psychosocial and medicaljoumals (Battjes 1988) addressing substance abuse and its therapy uncovered only two relevant studies. So little research has been done that it is not yet even certain that alcoholics, as a subgroup, find it more difficult to quit smoking than nonalcoholics, although data on the prevalence of smoking in recovering alcoholics suggest that this may be the case. In a survey conducted by Bobo and Gilchrist (1983), 57% of the treatment professionals who self-identified as recovering alcoholics reported current tobacco use, while only 30.4% of the nonalcoholics did so. These data must be interpreted with caution, however, as no indicator of any JourTUJI of Psy choactive Drugs
125
Vol. 24(2). Apr-Juri 1992
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BOBO
TABLE I RESPONDENT PERCEPTIONS OF THE EFFECT OF TRYING TO QUIT SMOKING ON MAINTENANCE OF SOBRIETY*
Nonsmokers (N=14)
Smokers
Total"
(N =53)
(N=73)
When I first quit smoking, I really wanted to drink again.
1.21
1.49
1.45
Sometimes the stress of trying to avoid cigare ttes has caused me to drink alcohol.
1.00
1.28
1.20
So metimes I am afraid that if I don't have a smoke, I will have a drink instead.
1.00
1.58
1.42
If you urge a reco vering alcoholi c who smokes cigar ettes to quit smoking , you might create so much stress for that person that he or she would start drinking again.
2.46
2.72
2 .71
Downloaded by [Australian National University] at 06:27 07 November 2015
Item
*Sco ring: l e strongly disagree; 2--mildly disagree; 3=rnildly agree; 4=strongly agree. **Total includes smokers, nonsmokers, and those with brief periods of tobacco abstinence whose smoking status was uncertain at the time of interv iew.
To parallel Miller, Hendrick and Taylor's analysis (1983), smoking and drinking status at the time of the interview were cross-tabulated. A 2x2 table was con structed to compare those who had abstained compl etely from drinking since discharge with those who had had at least one drink. Smokers were dichotomized according to current tobacco use, with those who had not smoked for two to five months excluded from the comparison. Almo st all of the nonsmokers (93%) but only 62 % of the smokers had uninterrupted alcohol abstinence.Using Fisher's two-tailed exact test for a comparison of proportions, this difference was found to be statistically significant (p
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
Nicotine Dependence and Alcoholism Epidemiology and Treatment Janet Kay Bobo To cite this article: Janet Kay Bobo (1992) Nicotine Dependence and Alcoholism Epidemiology and Treatment, Journal of Psychoactive Drugs, 24:2, 123-129, DOI: 10.1080/02791072.1992.10471633 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471633
Published online: 20 Jan 2012.
Submit your article to this journal
Article views: 15
View related articles
Citing articles: 29 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujpd20 Download by: [Australian National University]
Date: 07 November 2015, At: 06:27
Nicotine Dependence and
Downloaded by [Australian National University] at 06:27 07 November 2015
Alcoholism Epidemiology and Treatment JANET KAY BOBO, M.S.W.* Abstract-Nicotine dependence in alcohol-involved adults is a long-ignored treatment problem. The absence of its discussion in the literature is difficult to defend in light of medical and epidemiological data on the cost and prevalence of this dual addiction. Most descriptive studies of alcohol abusers published in the past 20 years have reported tobacco use rates of at least 90%. There is a crucial need to educate treatment professionals and their clients about the additional health risks associated with joint nicotine dependence and alcoholism. Historically, certain barriers to active intervention have existed in drug abuse treatment facilities, including (1) concerns that urging clients to quit smoking might have an adverse effect on their maintenance of sobriety, (2) a tendency to minimize the strength and severity of nicotine addiction, (3) a lack of informative data on how best to treat smoking in recovering alcoholics, and (4) financial issues related to marketing and insurance compensation. Recent data obtained from recovering alcoholics who have tried to quit smoking and anecdotal reports from alcoholism treatment centers that have begun addressing nicotine addiction are now challenging thesebarriers. Education,role modeling, environmental control, and development of staff expertise can be incorporated into standard alcoholism treatment programs to jointly treat these paired addictions. Keywords-alcohol-nicotine epidemiology, alcohol-nicotine health risks, alcohol-nicotine treatment
Twenty-five years ago the popularity of smoking among American males began to diminish. Over 50% of all adult men were smokers in 1965, but the figure had dropped to 33.5% by 1985 (Fioreetal.1989; Warner 1989).Tobacco's popularity continued to rise among women for several years after the Surgeon General's 1964 report (U.S. Department of Health, Education and Welfare 1964), but has, at least since 1974, declined steadily. In 1985, the prevalence of smoking among adult females was estimated to be 27.6%. Preliminary analyses of responses to the 1987 National Health Interview Survey suggest even lower percentages of 31.7% for men and 26.8% for women (Fiore et at. 1989). These data are in striking contrast to those obtained
from samples ofalcohol-involved adults. Dreher and Fraser (1967) collected tobacco use information on 103 alcoholic outpatients in 1965 and noted that 92.7% of the males and 90.5% of the females were smokers. Only two studies addressing nicotine dependence in alcoholics were reported in the 1970s (Bobo & Gilchrist 1983). Both studies focused exclusively on men and both showed even higher rates of 97% and 94% (Ayers, Ruff & Templer 1976; Walton 1972). In 1981, Ashley and colleagues reviewed 1,001 inpatient treatment center admissions occurring between 1967 and 1969, and found that 92.1 % of the males and 95.2% of the females were smokers (Ashley et al. 1981). A similar survey conducted on 1979-80 admissions showed somewhat lower estimates of86% and 82% for men and women, respectively (Kozlowski, Jelinek & Pope 1986). The most recently reported estimate, derived from a sample of male
-Research scientist, Department of Epidemiology, SC-36, University of Washington, Seattle, Washington 98195.
Journal
of Psychoactive Drugs
123
Vol. 24(2), Apr-Jun 1992
Downloaded by [Australian National University] at 06:27 07 November 2015
nono
NICOTINE & ALCOHOL
use of the two substances. The data reported by Blot and colleagues are iIlustrative. They identified all new, reported cases ofcertain types of oral/pharyngeal cancers in adult men and women in four regions of the United States in 1984-85. After obtaining alcohol and tobacco use histories from these 1,114 patients, they collected similar data from 1,268 age, race, and gender-matched individuals who had been randomly selected from the communities of the oral cancer cases. Their findings for males and females were quite similar, but results for the two groups were reported separately. Only the results for men, who constituted 68.4% of the sample, will be reviewed here . Among nonsmokers, it was found that men who were heavy drinkers (averaging 30 or more drinks per week) were 5.8 times more likely to develop an oral cancer than those who drank less than one alcoholic drink per week. Among nondrinkers, it was observed that men who were heavy smokers (two or more packs of cigarettes a day) were 7.4 times more likely to develop a cancer than those who were nonsmokers. Among the 169 men who had a history of heavy drinking and heavy smoking, the risk of disease was 37.7 times as great as that observed among those who drank rarely and did not smoke. On a more positive note, these researchers also found a sharp drop in risk associated with smoking cessation. After controlling for alcohol use history, they found only a 10% increase in risk (an odds ratio of 1.1 among former smokers who had not smoked for 10 years or more . They concluded that smoking must thus affect a relatively late stage in the process of oropharyngeal carcinogenesis. The implications of these findings to the recovering alcoholic who continues to smoke are clear. Yet, most chemical dependence treatment centers in the United States skirt or completely ignore the issue of nicotine addiction. In a 1983 survey of all licensed, inpatient alcoholism treatment centers (ATCs) in Washington state, no facility reported offering treatment of nicotine dependence concurrent with or subsequent to alcoholism treatment, even though 27% ofthe responding staff felt that such a program should be available for their clients (Bobo & Gilchrist 1983). A recent survey of 227 chemical dependence treatment facilities in Minnesota yielded similar results. Although 72.2% of the respondents felt that smoking should be addressed, only 11.2% of the programs included treatment of nicotine dependence in 1988 (Knapp 1989).
inpatient alcoholics in California, is depressingly consistent with the earlier studies: 90% of the surveyed alcoholics were found to be current smokers (Burling & Ziff 1988). Smoking also tends to be highly correlated with drinking among nonalcoholics. Many studies have found higher rates of smoking among heavy social drinkers compared to light or nondrinkers (Carmody et al. 1985; Istvan & Matarazzo 1984; Craig & VanNatta 1977). Why alcohol-involved adults are so much more likely to smoke remains unclear. Various theories have been proposed, including the presence ofan underlying addictive personality; the existence ofa stronger oral drive in alcoholics than nonalcoholics; a tendency for increased socialization in drinkers, which places them more frequently in the presence of other smokers; and the existence of biologic interactions associated with concurrent alcohol-tobacco consumption (McCoy & Napier 1986; Walton 1972). The evidence supporting each of these possibilities is fragmentary and will not be reviewed here. The objective of the present article is to highlight the barriers that continue to block widespread treatment of nicotine dependence in recovering alcoholics. The alcoholism treatment field, while progressive in many arenas, has failed to fully mirror the growing rejection of smok ing so evident in the general population. Chemical dependence treatment counselors need to be aware of these barriers and, equally important, of the work that is being done to surmountthem. To limit the scope of this review, two assumptions are made . The first is that alcoholics, recovering and otherwi se, continue to smoke largely because they, like heavy smokers in general, are addicted to nicotine (Kozlowski et al. 1989; U.S. Department of Health and Human Services 1989; Henningfield & Nemeth-Coslett 1988). The second assumption is that the health problems associated with smoking equal or exceed those associated with alcoholism. Because individuals who both drink and smoke face health risks even greater than those generally associated with smoking alone, and because these additional health risks are not widely appreciated, the synergistic effects of such paired consumption will be briefly reviewed first.
HEALTH EFFECTS OF SMOKING IN ALCOHOLICS The American Cancer Society (1988) has estimated that in 1987 alone there were at least 30,000 new cases of oral cancer and 9,000 deaths associated with such malignancies in the United States. Recent epidemiologic data suggest that the majority of those oral and pharyngeal cancers (80% in males, 61 % in females) were attributable to alcohol/tobacco consumption (Blot et al. 1988; Tuyns et aI. 1988; Flanders & Rothman 1982; Noble 1978). These high attributable risks reflect the multiplicative, or synergistic, increase in rates associated with paired, rather than isolated, Journal of Psychoacti ve Dru gs
BARRIERS TO TREATMENT OF NICOTiNE DEPENDENCE IN ALCOHOLICS Historically, four barriers have tended to limit opportunities for direct treatment of nicotine dependence in recovering alcoholics. 124
Vol. 24 (2). Apr-Juri 1992
NICOTINE & ALCOHOL
Downloaded by [Australian National University] at 06:27 07 November 2015
BOBO
desire to quit smoking was obtained. (Alcoholic respondents may have had higher rates of smoking simply because they had made fewer serious attempts to quit.) When asked directly about the perceived difficulLy of quitting smoking in alcoholics compared to nonalcoholics, the counselors were about equally divided between those who felt it was harder for alcoholics to quit (46%) and those who disagreed or were not sure (54%) . "The absence of an informative body of literature is of concern because there are at least three key questions that consistently arise. Specifically, will asking an alcoholic client to quit smoking have an adverse effect on his or her ability to remain sober? If not, when should clients first be urged to quit smoking? And finally, what treatment techniques are most likely to be effective? Before moving on to the fourth barrier to treatment, the two studies that have been reported to date will be reviewed briefly. Effectofsmokingcessationonsobriety. Miller, Hedrick and Taylor's published results (1983) of a two-year followup study of 93 graduates of a behavioral self-control intervention focused on the reduction of alcohol consumption. For 39 of the participants, they obtained data on tobacco use at pretest and at six-month follow-up . They found that among clients who started out as smokers but had quit smoking by the six-month interview, 100% were successfully controlling their drinking. By contrast, among the individuals who were not smoking at pretest but were at follow -up, none showed acceptable control of their drink ing.No data were presented for participants whose smoking status remained unchanged from pretest to follow-up. Most chemical dependence treatment units in the United States employ a treatment methodology based on total abstinence rather than on control of drinking. ATC counselors have expressed concern about the appropriateness of generalizing findings from the latter model to the former . At best, these data suggest that in one sample of problem drinkers, smoking cessation apparently had no negative effect on efforts to remain sober. More direct evidence comes from a study that interviewed 73 recovering male alcoholics who had made at least one serious attempt to quit smoking since diseharge from an intensive, inpatient alcohol treatment program (Bobo et al. 1987; Bobo et aI. 1986). Self-selected respondents gave detailed data on their alcohol and tobacco use histories, and completed the legal, work, and social problems subscale of the Michigan Alcoholism Screening Test (Hedlund & Vieweg 1984; Gibbs 1983; Skinner 1982), and answered a series of open-ended questions concerning the effect of their smoking cessation attempt on the maintenance of sobriety. To insure the accuracy of the self-report data, participants provided names, addresses, and phone numbers of "verifiers" who could corroborate their responses. Verifiers were contacted for a randomly-selected 12% of the sample, and, in all cases, they fully substantiated
Resistance Explicit resistance to such treatment is often voiced by ATC staff who fear that the stress of trying to quit smoking might jeopardize the tenuous process of recovery in some of their clients. Twenty-three percent of 311 alcoholism treatment professionals responding to a survey in Washington state (Bobo & Gilchrist 1983) indicated they would "never" favor urging an alcoholic client who smokes to quit smoking, even five years after the onset of sobriety; and 46 % reported that they would never personally encourage such cessation. In that sample, reported attitudes and behaviors were strongly associated with the personal tobacco and alcohol use histories of the respondents. Those who selfidentified as recovering alcoholics who continued to smoke were significantly more likely to oppose urging tobacco cessation attempts than were those who were neither regular smokers nor former drinkers. Minimizing the Sequelae The chemicaldependence treatmen tindustry has tended to regard nicotine use as less difficult to control and less serious in its sequelae than alcoholism and other so-called hard drug addictions. A considerable literature exists on the epidemiology and treatment of the multiple drug user, but tobacco use is rarely considered as a part of the syndrome (Battjes 1988). Kozlowski and colleagues (1989) recently reported results of a survey that asked persons seeking treatment for alcohol or other drug dependence to rate the difficulty of giving up smoking in comparison to the problem substance for which they were seeking treatment. Seventy-four percent said that cigarettes would be at least as difficult to quit using as the substance for which they were being treated. These data, in conjunction with those presented in the Surgeon General's recent report on the health consequences of nicotine addiction (U.S. Depart ment of Health and Human Services 1988), should help leverage a shift in thinking toward a more realistic appraisal of nicotine's potency. Lack of Literature The paucity ofliterature on the treatment of smoking in alcoholics creates a third barrier. A thorough review of the psychosocial and medicaljoumals (Battjes 1988) addressing substance abuse and its therapy uncovered only two relevant studies. So little research has been done that it is not yet even certain that alcoholics, as a subgroup, find it more difficult to quit smoking than nonalcoholics, although data on the prevalence of smoking in recovering alcoholics suggest that this may be the case. In a survey conducted by Bobo and Gilchrist (1983), 57% of the treatment professionals who self-identified as recovering alcoholics reported current tobacco use, while only 30.4% of the nonalcoholics did so. These data must be interpreted with caution, however, as no indicator of any JourTUJI of Psy choactive Drugs
125
Vol. 24(2). Apr-Juri 1992
NICOTI NE & ALCOHOL
BOBO
TABLE I RESPONDENT PERCEPTIONS OF THE EFFECT OF TRYING TO QUIT SMOKING ON MAINTENANCE OF SOBRIETY*
Nonsmokers (N=14)
Smokers
Total"
(N =53)
(N=73)
When I first quit smoking, I really wanted to drink again.
1.21
1.49
1.45
Sometimes the stress of trying to avoid cigare ttes has caused me to drink alcohol.
1.00
1.28
1.20
So metimes I am afraid that if I don't have a smoke, I will have a drink instead.
1.00
1.58
1.42
If you urge a reco vering alcoholi c who smokes cigar ettes to quit smoking , you might create so much stress for that person that he or she would start drinking again.
2.46
2.72
2 .71
Downloaded by [Australian National University] at 06:27 07 November 2015
Item
*Sco ring: l e strongly disagree; 2--mildly disagree; 3=rnildly agree; 4=strongly agree. **Total includes smokers, nonsmokers, and those with brief periods of tobacco abstinence whose smoking status was uncertain at the time of interv iew.
To parallel Miller, Hendrick and Taylor's analysis (1983), smoking and drinking status at the time of the interview were cross-tabulated. A 2x2 table was con structed to compare those who had abstained compl etely from drinking since discharge with those who had had at least one drink. Smokers were dichotomized according to current tobacco use, with those who had not smoked for two to five months excluded from the comparison. Almo st all of the nonsmokers (93%) but only 62 % of the smokers had uninterrupted alcohol abstinence.Using Fisher's two-tailed exact test for a comparison of proportions, this difference was found to be statistically significant (p
