Accepted Manuscript Title: Predictors of quit attempts and successful quit attempts among individuals with alcohol use disorders in a nationally representative sample Author: Viviana Chiappetta Olaya Garc´ıa-Rodr´ıguez Chelsea J. Jin Roberto Secades-Villa Carlos Blanco PII: DOI: Reference:
S0376-8716(14)00901-6 http://dx.doi.org/doi:10.1016/j.drugalcdep.2014.05.019 DAD 5170
To appear in:
Drug and Alcohol Dependence
Received date: Revised date: Accepted date:
4-2-2014 21-5-2014 22-5-2014
Please cite this article as: Chiappetta, V., Garc´ia-Rodr´iguez, O., Jin, C.J., SecadesVilla, R., Blanco, C.,Predictors of quit attempts and successful quit attempts among individuals with alcohol use disorders in a nationally representative sample, Drug and Alcohol Dependence (2014), http://dx.doi.org/10.1016/j.drugalcdep.2014.05.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Predictors of quit attempts and successful quit attempts among individuals with alcohol use
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disorders in a nationally representative sample
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Viviana Chiappettaa, Olaya García-Rodrígueza,b, Chelsea J. Jina, Roberto Secades-Villaa,b and
New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and
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Carlos Blancoa
Surgeons of Columbia University, New York, NY 10032, USA
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Department of Psychology, University of Oviedo, 33003, Oviedo, Spain
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*Corresponding author: Carlos Blanco New York State Psychiatric Institute Department of Psychiatry, College of Physicians and Surgeons of Columbia University 1051 Riverside Drive, Unit 69 New York, NY 10032, USA Tel.: +1 212 543 6533 Fax: +1 212 543 6515
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2 ABSTRACT Background: This study sought to identify predictors of attempting to quit and of successfully quitting alcohol abuse or dependence in the general population. Methods: Data were drawn
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from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
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Results: Approximately 10% of individuals with alcohol abuse and 18% of those with
dependence attempted to quit over the three year follow-up period. Of those who tried, 38% of
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individuals with abuse and 30% of those with dependence successfully quit. Among individuals
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with alcohol abuse or dependence, being single, younger than 40 years old, having low income, a co-occurring psychiatric disorder and greater number of dependence symptoms increased the
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likelihood of attempting to quit. Among individuals with alcohol abuse, male gender and low educational attainment further increased the odds of quit attempts. However, greater severity of
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alcohol use disorder, having a co-occurring drug use disorder and greater number of psychiatric
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disorders decreased the odds of success among individuals with alcohol abuse, while female
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gender, being married and older than 40 years old increased the odds of success. Among individuals with alcohol dependence, having nicotine dependence, greater number of psychiatric disorders and personality disorders decreased the odds of success. Conclusions: Predictors of attempts to quit are different and sometimes opposite from those leading to successful quitting probably indicating that some factors that increase motivation may decrease ability to quit. These findings may help in the development of more targeted and effective interventions for alcohol use disorders. KEYWORDS: alcohol abuse; alcohol dependence; quit attempts; national sample; NESARC.
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3 1. INTRODUCTION Each year nearly 80,000 people die from alcohol-related causes, making alcohol use the third leading preventable cause of death in the United States (Michaud et al., 2006; Mokdad et
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al., 2004; Rehm et al., 2009). Alcohol use disorders (alcohol abuse and dependence) are also
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responsible for myriad medical, psychological, social, economic and personal problems (World Health Organization 2004; Rubio et al., 2014), while reductions in problem drinking are
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associated with improved quality of life (Rubio et al., 2013; Watson, 1999), decline in mortality
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rates (Cuijpers et al., 2004) and lower healthcare costs (Bray et al., 2011). Although rates of treatment seeking are higher for alcohol problems than for any other substance use disorder
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(World Health Organization, 2010), the rates of successful treatments continue to be modest (Fachini et al., 2012; Franck and Jayaram-Lindstrom, 2013; Klingemann et al., 2009; Kranzler
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and Van Kirk, 2001; Mdege et al., 2013; Sobell et al., 2002), suggesting that predictors of
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attempt to quit could be different from those of successful quitting.
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In clinical studies, male gender (Kranzler et al., 1996), lower income (Noda et al., 2001), severity of dependence (Kadden et al., 1998; Zywiak et al., 2002) and presence of comorbid mood (Adamson et al., 2009) or personality disorders (Gianoli et al., 2012) have been identified as key contributors to unsuccessful quit attempts. However, these studies relied on clinical samples whose results may not extrapolate to the general population (Blanco et al., 2008a, 2008b; Humphreys, 2003; Humphreys et al., 2007; Okuda et al., 2010; Hoertel et al., 2012), where most individuals attempt to quit without professional help (Klingemann et al., 2009; Mohatt et al., 2008; Sobell et al., 2000). Similarly, some community studies have sought to identify predictors of remission (Kushner et al., 1999; Moos and Moos, 2006, 2007; Saha et al., 2006) but, to date, no study has examined predictors of quit attempts and whether those predictors also
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4 predict success at quitting. Identifying predictors of quit attempts is important because they indicate which individuals may be willing to stop alcohol use. Identifying predictors of successful quit attempts is also important because they indicate which individuals are likely to
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quit and which ones, despite their interest in quitting, may have difficulties doing so (FlórezSalamanca et al., 2013; García-Rodríguez et al., 2013; Hasin et al., 2011). Groups with low
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successful rates may then be the focus of more targeted interventions to increase successful quit
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rates.
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Because predictors of quit attempts and successful quit attempts have been found to differ in other substances (Rafful et al., 2013), we sought to address an important gap in knowledge by
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examining whether those findings extended to alcohol use disorders. Specifically, we sought to investigate in a nationally representative sample of US adults, sociodemographic and clinical
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2.1. Sample and procedures
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2. METHODS
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predictors of: 1) quit attempts and, 2) successful quit attempts of alcohol abuse and dependence.
The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant et al., 2009; Grant et al., 2004) was the source of data. The NESARC target population at Wave 1 was the civilian non-institutionalized population 18 years and older residing in households and group quarters. Interviews were conducted with 43,093 participants by experienced lay interviewers (Grant et al., 2009, 2004). All procedures, including informed consent, received full human subjects review and approval from the US Census Bureau and the US Office of Management and Budget. The Wave 2 interview was conducted approximately 3 years later and had a response rate of 86.7% (n= 34,653; Grant et al., 2009). As described previously, adjustment for non-response was successful, as the Wave 2 respondents and the
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5 original target population did not differ on age, race/ethnicity, gender, socioeconomic status, or the presence of any substance, mood, anxiety, or personality disorder (Grant et al., 2009). Participants included in the present study were those with Wave 2 data who met DSM-IV criteria
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for past-year alcohol abuse (n=3164) or dependence (n=656) in Wave 1 and had no attempts to
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quit prior to Wave 1.
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2.2. Measures
The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV
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Version (AUDADIS-IV) (Grant et al., 2001), a structured diagnostic interview that includes computer algorithms to generate DSM-IV diagnoses, was used. In order to build a
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comprehensive predictive model of quit attempts, we examined a broad range of sociodemographic, psychopathological, alcohol use-related variables and medical morbidity as
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assessed at baseline (i.e., Wave 1). Sociodemographic characteristics included age, gender,
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race/ethnicity, individual income, marital status, and level of education.
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Axis I psychiatric disorders included substance use, mood, and anxiety disorders while Axis II included personality disorders. The test-retest reliabilities for AUDADIS-IV diagnoses are fair to good for mood, anxiety, and personality disorders (κ= 0.40-0.62) and excellent for substance use disorders (κ= 0.70-0.91; Grant et al., 2009; Hasin et al., 2007). A diagnosis of alcohol abuse required that at least 1 or more of the 4 DSM-IV criteria were present at some time in the 12-month period preceding the interview and that concurrently the criteria for DSM-IV alcohol dependence were not met. A diagnosis of alcohol dependence required meeting 3 or more DSM-IV criteria for alcohol dependence in the 12-month period preceding the interview. In addition, the total number of symptoms of dependence and other clinical data related to alcohol use, tobacco use and previous hospitalizations for the treatment of
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6 SUD or other psychiatric disorders were also examined. Individuals were considered to have attempted to quit if the reported attempting to quit at any time between Waves 1 and 2.
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2.3. Statistical analysis First, we compared individuals with 12-month alcohol abuse or dependence at Wave 1
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who attempted to quit between Waves 1 and 2 versus those who did not attempt to quit. Second,
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among the respondents with quit attempts, we compared those who still met criteria for alcohol abuse or dependence (i.e., had an unsuccessful quit attempt) versus those who did not fulfill
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criteria for any alcohol use disorder at Wave 2 (i.e., had successful quit attempt). In both analyses we used logistic regression to obtain odds ratios (ORs) as well as 95% confidence
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intervals (95% CI) of sociodemographic characteristics, substance use-related variables, psychiatric comorbidity and physical health conditions. All analyses were conducted using
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3. RESULTS
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SUDAAN (Research Triangle Institute, 2007) to adjust for the design effects of the NESARC.
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3.1. Probability of quit attempts and successful quit attempts Only a small proportion (10.6%, n=353) of individuals with alcohol abuse with no previous attempts to quit at Wave 1 tried to quit between Waves 1 and 2. Of those who attempted to quit, 37.6% succeeded, whereas almost two thirds (n= 214) still met criteria for alcohol abuse at Wave 2.
Among individuals with alcohol dependence, only 17.7% (n =108) without previous attempts at baseline attempted to quit between Wave 1 and Wave 2. Of those, 30.2% (n=38) of individuals succeeded, whereas more than two thirds still met criteria for alcohol dependence at Wave 2.
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7 3.2. Predictors of quit attempts and successful quit attempts among individuals with alcohol abuse Several sociodemographic, alcohol use-related characteristics and co-occurring
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psychiatric disorders predicted attempting to quit and successful quitting. Being non-white,
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younger than 40 years old, divorced/separated/widowed or never married and having less than high school education significantly increased the odds of attempting to quit, whereas being
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female and having an income above $20,000 decreased the odds of attempting to quit. Greater
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daily alcohol consumption and higher number of symptoms of dependence were associated to increased odds of attempting to quit. Having a comorbid drug use disorder, a personality disorder
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and a greater number of psychiatric disorders also increased the odds of attempting to quit. Age at first use of alcohol, all tobacco use-related variables, having a mood or anxiety disorder and
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previous psychiatric hospitalizations failed to predict attempting to quit (Table1).
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In contrast with the predictors of quit attempts, being female, older than 40 years of age
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and being married predicted successful quitting by Wave 2. Greater number of alcohol dependence criteria decreased the odds of successful attempts. Also, respondents who ever used tobacco and those with a drug use disorder or greater number of psychiatric disorders were less likely to succeed. Race/ethnicity, individual income, educational attainment, age at first alcohol use, having a mood, anxiety or personality disorder or tobacco dependence, and previous hospitalizations did not predict success in quitting (Table 2). 3.3. Predictors of quit attempts and successful quit attempts among individuals with alcohol dependence Being younger than 40 years of age and divorced/separated/widowed or never married significantly increased the odds of attempting to quit whereas having an income above $20,000
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8 decreased the odds of attempting to quit. Greater number of alcohol dependence criteria, having a comorbid drug use disorder, and a greater number of psychiatric disorders also increased the odds of attempting to quit. Race/ethnicity, sex, education, alcohol daily used and age at first use,
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hospitalizations did not predict attempting to quit (Table 3).
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any tobacco-related variable, having a mood, anxiety or personality disorder and previous
Nicotine dependence, greater number of psychiatric disorders and a personality disorder
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decreased the odds of successful attempts. There were no predictors that increased the odds of
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successful attempts. Race/ethnicity, sex, age, annual income, any alcohol use-related variables, have ever used tobacco, having a mood, anxiety or other drug use disorder did not predict
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success in quitting (Table 4). 4. DISCUSSION
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In a large national sample of US adults with alcohol use disorders, approximately 10% of
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individuals with alcohol abuse and 18% of those with dependence attempted to quit over a three-
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year period. Of those who tried, 38% of individuals with abuse and 30% of those with dependence successfully quit. Individuals with alcohol abuse or dependence who tried to quit were more likely to be single, younger than 40 years of age, have annual income below $20,000, meet greater number of criteria for alcohol dependence and have higher number of co-occurring psychiatric disorders. Furthermore, individuals with alcohol abuse who attempted to quit were more likely to be non-white, male and to have lower than high school education. By contrast, lower severity of alcohol use disorder, absence of nicotine dependence and lower number of co-occurring psychiatric disorders predicted successful quit attempts among individuals with alcohol abuse or dependence. Furthermore, being female, married and older than 40 years of age also predicted successful attempts among individuals with alcohol abuse.
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9 A small proportion of individuals with alcohol use disorders (10.6% of individuals with abuse and 17.7% of those with dependence) attempted to quit in a three-year period. These rates are difficult to compare with those of other studies, because we are not aware of any other
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studies that have examined rates of quit attempts for alcohol use disorders at the population level. However, our data are consistent with studies that have found that only a minority of individuals
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with alcohol-related problems seek help for those problems (Madras et al., 2009; World Health
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Organization, 2011) and with the overall cultural acceptance (Cook and Reuter, 2007) of alcohol use. At the same time, the rates of quit attempts for alcohol use disorders documented in this
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study appear considerably lower than those previously documented for smoking (Rafful et al., 2013). Ongoing public health efforts in antismoking media campaigns (Emery et al., 2012),
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increased public awareness of negative health consequences (Federal Trade Commission., 2003)
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differences in rates of quit attempts.
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and smoking restrictions in public spaces (Pierce et al., 2011) may have contributed to these
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We found that rates of successful quitting attempts among individuals with alcohol use disorders were around 30%. Although these rates are low, they are considerable higher than the 5% successful attempts for quitting smoking (Rafful et al., 2013). These rates are consistent with the higher remission rates from alcohol than nicotine dependence (Lopez-Quintero et al., 2011a) and may be related to the speed at which physical, psychological and social adverse consequences of alcohol dependence manifest (Chen and Lin, 2009). Given the severe, but often reversible consequences of alcohol use disorders in multiple domains (Alfonso-Loeches and Guerri, 2011; Allen et al., 2011; Rehm et al., 2003, 2009; Roerecke and Rehm, 2012; Rubio et al., 2013; Saarni et al., 2007; Saatcioglu et al., 2008; Samokhvalov et al., 2010) our data identify an important area of opportunity to improve public health.
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10 Consistent with prior studies (Boschloo et al., 2012; Satre et al., 2003; Weisner, 1993; Wilsnack et al., 2000, 2009), we found that male sex, younger age, being single, and having low socioeconomic status increased the odds of attempting to quit. Greater social pressure and fewer
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social resources may increase the need and motivation of these individuals to quit substance use (Cunningham et al., 1994; Weisner et al., 2001; Blanco et al., 2013). In addition, comorbidity
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with other drug and psychiatric disorders further increased the odds of quit attempts. Awareness
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of accumulating harms effect (Orford et al., 2006, 2009), distress (Cunningham et al., 1995; Sobell et al., 1993), and social pressure (George and Tucker, 1996; Hasin, 1994) may act as
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potential triggers for attempting to quit among individuals with alcohol use disorders.
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Our study found that being a female, married and older than 40 years of age increased the odds of successful quit attempts, whereas greater severity of alcohol use disorders and greater
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number of comorbid disorders, including other drug use disorders, decreased the odds of
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successful attempts. The demands of more consolidated adult roles and responsibilities as well as
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increased social support may contribute to explaining the protective effect of certain demographic characteristics (Bjork et al., 2008; Karlamangla et al., 2006). By contrast, more severe psychopathology, including substance-related psychopathology (Blanco et al., 2013b; Koob and Volkow, 2009; Lopez-Quintero et al., 2011a, 2011b; Marlowe et al., 1997; Schmidt and Sander, 2000; Thomas et al., 1999) may promote the use of maladaptive coping skills (Dolan et al., 2013; McNally et al., 2003; Wedekind et al., 2013; Blanco et al., 2014) and result in a reduction of the ability to quit. More generally, the results of study suggest that variables that increase the likelihood of attempts paradoxically tend to predict the failure of those attempts. Factors that may motivate individuals to quit (such as greater symptom severity, greater psychopathology or lower psychosocial support) may reflect greater objective or subjective need
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11 to stop substance use, but also lower the ability to muster the resources to attain or maintain abstinence (Secades-Villa et al., 2013). Approaches that seek to decrease the prevalence of alcohol use disorders should consider the paradoxical effects of these factors.
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This study has some limitations. First, the NESARC did not collect information about the
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reasons for quitting, which may be important predictors of success. Second, information of
alcohol abuse and dependence was based on self-report and not confirmed by objective methods.
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Third, the sample was restricted to individuals 18 and older. Our findings may not generalize to
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younger individuals.
Although alcohol abuse and dependence are highly disabling disorders, rates of attempt
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to quit are extremely low and among those who attempt to quit only about a third succeed. Several sociodemographic and clinical characteristics predict quit attempts, but among those
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attempt to quit many of those characteristics predict unsuccessful attempts, probably indicating
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that those with greatest need and motivation to quit maybe also those with more difficulty
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quitting. We hope this information may be useful for the development of more targeted and effective interventions for alcohol use disorders.
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Author Disclosures
Role of Funding Sources Funding for this study was provided in parts by NIH grants DA019606, DA023200, CA133050 and the New York State Psychiatric Institute (Dr. Blanco). The NIH and the NYSPI had no further role in the study design, collection, analysis or interpretation of the data, the writing of the manuscript or the decision to submit the paper for publication.
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ed
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Conflict of Interest All the authors declare that they have no conflicts of interest.
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Contributors Carlos Blanco designed the study. Viviana Chiappetta and Roberto Secades-Villa provided summaries of previous research. Chelsea J. Jin undertook the statistical analysis and Viviana Chiappetta and Olaya García-Rodríguez wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
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Table
1 Table 1. Characteristics of individuals with alcohol abuse with and without attempts to quit in a 3-year period. Wave 1 NESARC 2001-2002 (n = 3,164).
73.23 26.77
2188 623
248 105
71.75 28.25
1636 1175
197 156
56.62 43.38
129 224
95% CI
p-value
1.00 2.28
1.00 1.73
1.00 3.01
N/A =High school Alcohol use Alcohol daily use b Age at first use
No attempts to quit (n = 548) n %a/mean
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Attempts to quit (n = 108) n %a/mean
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Table 3. Characteristics of individuals with alcohol dependence with and without attempts to quit in a 3year period. Wave 1 NESARC 2001-2002 (n = 656).
OR
95% CI
p-value
76.37 23.63
426 122
83.87 16.13
1.00 1.61
1.00 0.93
1.00 2.78
N/A 0.0870
65 43
64.66 35.34
301 247
61.5 38.5
1.00 0.87
1.00 0.49
1.00 1.54
N/A 0.6354
87.08 12.92
377 171
71.61 28.39
2.67 1.00
1.54 1.00
4.63 1.00
0.0007 N/A
60.47 39.53
207 341
39.6 60.4
1.00 0.43
1.00 0.25
1.00 0.72
N/A 0.0018
36 72
33.27 66.73
262 286
54.04 45.96
1.00 2.36
1.00 1.39
1.00 4.01
N/A 0.0020
9 99
6.5 93.5
42 506
7.18 92.82
0.90 1.00
0.37 1.00
2.20 1.00
0.8129 N/A
16 107 108
12.84 21.47 2.55
39 543 548
7.62 21.44 1.25
1.79 1.00 1.55
0.85 0.98 1.34
3.77 1.03 1.81
0.1256 0.9615 =High school Alcohol use Alcohol daily use b Age at first use
No attempts to quit (n = 548) n %a/mean
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Attempts to quit (n = 108) n %a/mean
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Table 3. Characteristics of individuals with alcohol dependence with and without attempts to quit in a 3year period. Wave 1 NESARC 2001-2002 (n = 656).
OR
95% CI
p-value
76.37 23.63
426 122
83.87 16.13
1.00 1.61
1.00 0.93
1.00 2.78
N/A 0.0870
65 43
64.66 35.34
301 247
61.5 38.5
1.00 0.87
1.00 0.49
1.00 1.54
N/A 0.6354
87.08 12.92
377 171
71.61 28.39
2.67 1.00
1.54 1.00
4.63 1.00
0.0007 N/A
60.47 39.53
207 341
39.6 60.4
1.00 0.43
1.00 0.25
1.00 0.72
N/A 0.0018
36 72
33.27 66.73
262 286
54.04 45.96
1.00 2.36
1.00 1.39
1.00 4.01
N/A 0.0020
9 99
6.5 93.5
42 506
7.18 92.82
0.90 1.00
0.37 1.00
2.20 1.00
0.8129 N/A
16 107 108
12.84 21.47 2.55
39 543 548
7.62 21.44 1.25
1.79 1.00 1.55
0.85 0.98 1.34
3.77 1.03 1.81
0.1256 0.9615
S0376-8716(14)00901-6 http://dx.doi.org/doi:10.1016/j.drugalcdep.2014.05.019 DAD 5170
To appear in:
Drug and Alcohol Dependence
Received date: Revised date: Accepted date:
4-2-2014 21-5-2014 22-5-2014
Please cite this article as: Chiappetta, V., Garc´ia-Rodr´iguez, O., Jin, C.J., SecadesVilla, R., Blanco, C.,Predictors of quit attempts and successful quit attempts among individuals with alcohol use disorders in a nationally representative sample, Drug and Alcohol Dependence (2014), http://dx.doi.org/10.1016/j.drugalcdep.2014.05.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Predictors of quit attempts and successful quit attempts among individuals with alcohol use
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disorders in a nationally representative sample
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Viviana Chiappettaa, Olaya García-Rodrígueza,b, Chelsea J. Jina, Roberto Secades-Villaa,b and
New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and
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Carlos Blancoa
Surgeons of Columbia University, New York, NY 10032, USA
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Department of Psychology, University of Oviedo, 33003, Oviedo, Spain
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*Corresponding author: Carlos Blanco New York State Psychiatric Institute Department of Psychiatry, College of Physicians and Surgeons of Columbia University 1051 Riverside Drive, Unit 69 New York, NY 10032, USA Tel.: +1 212 543 6533 Fax: +1 212 543 6515
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2 ABSTRACT Background: This study sought to identify predictors of attempting to quit and of successfully quitting alcohol abuse or dependence in the general population. Methods: Data were drawn
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from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
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Results: Approximately 10% of individuals with alcohol abuse and 18% of those with
dependence attempted to quit over the three year follow-up period. Of those who tried, 38% of
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individuals with abuse and 30% of those with dependence successfully quit. Among individuals
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with alcohol abuse or dependence, being single, younger than 40 years old, having low income, a co-occurring psychiatric disorder and greater number of dependence symptoms increased the
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likelihood of attempting to quit. Among individuals with alcohol abuse, male gender and low educational attainment further increased the odds of quit attempts. However, greater severity of
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alcohol use disorder, having a co-occurring drug use disorder and greater number of psychiatric
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disorders decreased the odds of success among individuals with alcohol abuse, while female
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gender, being married and older than 40 years old increased the odds of success. Among individuals with alcohol dependence, having nicotine dependence, greater number of psychiatric disorders and personality disorders decreased the odds of success. Conclusions: Predictors of attempts to quit are different and sometimes opposite from those leading to successful quitting probably indicating that some factors that increase motivation may decrease ability to quit. These findings may help in the development of more targeted and effective interventions for alcohol use disorders. KEYWORDS: alcohol abuse; alcohol dependence; quit attempts; national sample; NESARC.
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3 1. INTRODUCTION Each year nearly 80,000 people die from alcohol-related causes, making alcohol use the third leading preventable cause of death in the United States (Michaud et al., 2006; Mokdad et
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al., 2004; Rehm et al., 2009). Alcohol use disorders (alcohol abuse and dependence) are also
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responsible for myriad medical, psychological, social, economic and personal problems (World Health Organization 2004; Rubio et al., 2014), while reductions in problem drinking are
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associated with improved quality of life (Rubio et al., 2013; Watson, 1999), decline in mortality
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rates (Cuijpers et al., 2004) and lower healthcare costs (Bray et al., 2011). Although rates of treatment seeking are higher for alcohol problems than for any other substance use disorder
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(World Health Organization, 2010), the rates of successful treatments continue to be modest (Fachini et al., 2012; Franck and Jayaram-Lindstrom, 2013; Klingemann et al., 2009; Kranzler
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and Van Kirk, 2001; Mdege et al., 2013; Sobell et al., 2002), suggesting that predictors of
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attempt to quit could be different from those of successful quitting.
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In clinical studies, male gender (Kranzler et al., 1996), lower income (Noda et al., 2001), severity of dependence (Kadden et al., 1998; Zywiak et al., 2002) and presence of comorbid mood (Adamson et al., 2009) or personality disorders (Gianoli et al., 2012) have been identified as key contributors to unsuccessful quit attempts. However, these studies relied on clinical samples whose results may not extrapolate to the general population (Blanco et al., 2008a, 2008b; Humphreys, 2003; Humphreys et al., 2007; Okuda et al., 2010; Hoertel et al., 2012), where most individuals attempt to quit without professional help (Klingemann et al., 2009; Mohatt et al., 2008; Sobell et al., 2000). Similarly, some community studies have sought to identify predictors of remission (Kushner et al., 1999; Moos and Moos, 2006, 2007; Saha et al., 2006) but, to date, no study has examined predictors of quit attempts and whether those predictors also
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4 predict success at quitting. Identifying predictors of quit attempts is important because they indicate which individuals may be willing to stop alcohol use. Identifying predictors of successful quit attempts is also important because they indicate which individuals are likely to
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quit and which ones, despite their interest in quitting, may have difficulties doing so (FlórezSalamanca et al., 2013; García-Rodríguez et al., 2013; Hasin et al., 2011). Groups with low
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successful rates may then be the focus of more targeted interventions to increase successful quit
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rates.
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Because predictors of quit attempts and successful quit attempts have been found to differ in other substances (Rafful et al., 2013), we sought to address an important gap in knowledge by
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examining whether those findings extended to alcohol use disorders. Specifically, we sought to investigate in a nationally representative sample of US adults, sociodemographic and clinical
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2.1. Sample and procedures
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2. METHODS
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predictors of: 1) quit attempts and, 2) successful quit attempts of alcohol abuse and dependence.
The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant et al., 2009; Grant et al., 2004) was the source of data. The NESARC target population at Wave 1 was the civilian non-institutionalized population 18 years and older residing in households and group quarters. Interviews were conducted with 43,093 participants by experienced lay interviewers (Grant et al., 2009, 2004). All procedures, including informed consent, received full human subjects review and approval from the US Census Bureau and the US Office of Management and Budget. The Wave 2 interview was conducted approximately 3 years later and had a response rate of 86.7% (n= 34,653; Grant et al., 2009). As described previously, adjustment for non-response was successful, as the Wave 2 respondents and the
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5 original target population did not differ on age, race/ethnicity, gender, socioeconomic status, or the presence of any substance, mood, anxiety, or personality disorder (Grant et al., 2009). Participants included in the present study were those with Wave 2 data who met DSM-IV criteria
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for past-year alcohol abuse (n=3164) or dependence (n=656) in Wave 1 and had no attempts to
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quit prior to Wave 1.
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2.2. Measures
The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV
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Version (AUDADIS-IV) (Grant et al., 2001), a structured diagnostic interview that includes computer algorithms to generate DSM-IV diagnoses, was used. In order to build a
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comprehensive predictive model of quit attempts, we examined a broad range of sociodemographic, psychopathological, alcohol use-related variables and medical morbidity as
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assessed at baseline (i.e., Wave 1). Sociodemographic characteristics included age, gender,
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race/ethnicity, individual income, marital status, and level of education.
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Axis I psychiatric disorders included substance use, mood, and anxiety disorders while Axis II included personality disorders. The test-retest reliabilities for AUDADIS-IV diagnoses are fair to good for mood, anxiety, and personality disorders (κ= 0.40-0.62) and excellent for substance use disorders (κ= 0.70-0.91; Grant et al., 2009; Hasin et al., 2007). A diagnosis of alcohol abuse required that at least 1 or more of the 4 DSM-IV criteria were present at some time in the 12-month period preceding the interview and that concurrently the criteria for DSM-IV alcohol dependence were not met. A diagnosis of alcohol dependence required meeting 3 or more DSM-IV criteria for alcohol dependence in the 12-month period preceding the interview. In addition, the total number of symptoms of dependence and other clinical data related to alcohol use, tobacco use and previous hospitalizations for the treatment of
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6 SUD or other psychiatric disorders were also examined. Individuals were considered to have attempted to quit if the reported attempting to quit at any time between Waves 1 and 2.
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2.3. Statistical analysis First, we compared individuals with 12-month alcohol abuse or dependence at Wave 1
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who attempted to quit between Waves 1 and 2 versus those who did not attempt to quit. Second,
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among the respondents with quit attempts, we compared those who still met criteria for alcohol abuse or dependence (i.e., had an unsuccessful quit attempt) versus those who did not fulfill
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criteria for any alcohol use disorder at Wave 2 (i.e., had successful quit attempt). In both analyses we used logistic regression to obtain odds ratios (ORs) as well as 95% confidence
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intervals (95% CI) of sociodemographic characteristics, substance use-related variables, psychiatric comorbidity and physical health conditions. All analyses were conducted using
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3. RESULTS
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SUDAAN (Research Triangle Institute, 2007) to adjust for the design effects of the NESARC.
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3.1. Probability of quit attempts and successful quit attempts Only a small proportion (10.6%, n=353) of individuals with alcohol abuse with no previous attempts to quit at Wave 1 tried to quit between Waves 1 and 2. Of those who attempted to quit, 37.6% succeeded, whereas almost two thirds (n= 214) still met criteria for alcohol abuse at Wave 2.
Among individuals with alcohol dependence, only 17.7% (n =108) without previous attempts at baseline attempted to quit between Wave 1 and Wave 2. Of those, 30.2% (n=38) of individuals succeeded, whereas more than two thirds still met criteria for alcohol dependence at Wave 2.
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7 3.2. Predictors of quit attempts and successful quit attempts among individuals with alcohol abuse Several sociodemographic, alcohol use-related characteristics and co-occurring
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psychiatric disorders predicted attempting to quit and successful quitting. Being non-white,
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younger than 40 years old, divorced/separated/widowed or never married and having less than high school education significantly increased the odds of attempting to quit, whereas being
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female and having an income above $20,000 decreased the odds of attempting to quit. Greater
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daily alcohol consumption and higher number of symptoms of dependence were associated to increased odds of attempting to quit. Having a comorbid drug use disorder, a personality disorder
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and a greater number of psychiatric disorders also increased the odds of attempting to quit. Age at first use of alcohol, all tobacco use-related variables, having a mood or anxiety disorder and
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previous psychiatric hospitalizations failed to predict attempting to quit (Table1).
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In contrast with the predictors of quit attempts, being female, older than 40 years of age
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and being married predicted successful quitting by Wave 2. Greater number of alcohol dependence criteria decreased the odds of successful attempts. Also, respondents who ever used tobacco and those with a drug use disorder or greater number of psychiatric disorders were less likely to succeed. Race/ethnicity, individual income, educational attainment, age at first alcohol use, having a mood, anxiety or personality disorder or tobacco dependence, and previous hospitalizations did not predict success in quitting (Table 2). 3.3. Predictors of quit attempts and successful quit attempts among individuals with alcohol dependence Being younger than 40 years of age and divorced/separated/widowed or never married significantly increased the odds of attempting to quit whereas having an income above $20,000
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8 decreased the odds of attempting to quit. Greater number of alcohol dependence criteria, having a comorbid drug use disorder, and a greater number of psychiatric disorders also increased the odds of attempting to quit. Race/ethnicity, sex, education, alcohol daily used and age at first use,
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hospitalizations did not predict attempting to quit (Table 3).
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any tobacco-related variable, having a mood, anxiety or personality disorder and previous
Nicotine dependence, greater number of psychiatric disorders and a personality disorder
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decreased the odds of successful attempts. There were no predictors that increased the odds of
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successful attempts. Race/ethnicity, sex, age, annual income, any alcohol use-related variables, have ever used tobacco, having a mood, anxiety or other drug use disorder did not predict
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success in quitting (Table 4). 4. DISCUSSION
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In a large national sample of US adults with alcohol use disorders, approximately 10% of
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individuals with alcohol abuse and 18% of those with dependence attempted to quit over a three-
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year period. Of those who tried, 38% of individuals with abuse and 30% of those with dependence successfully quit. Individuals with alcohol abuse or dependence who tried to quit were more likely to be single, younger than 40 years of age, have annual income below $20,000, meet greater number of criteria for alcohol dependence and have higher number of co-occurring psychiatric disorders. Furthermore, individuals with alcohol abuse who attempted to quit were more likely to be non-white, male and to have lower than high school education. By contrast, lower severity of alcohol use disorder, absence of nicotine dependence and lower number of co-occurring psychiatric disorders predicted successful quit attempts among individuals with alcohol abuse or dependence. Furthermore, being female, married and older than 40 years of age also predicted successful attempts among individuals with alcohol abuse.
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9 A small proportion of individuals with alcohol use disorders (10.6% of individuals with abuse and 17.7% of those with dependence) attempted to quit in a three-year period. These rates are difficult to compare with those of other studies, because we are not aware of any other
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studies that have examined rates of quit attempts for alcohol use disorders at the population level. However, our data are consistent with studies that have found that only a minority of individuals
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with alcohol-related problems seek help for those problems (Madras et al., 2009; World Health
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Organization, 2011) and with the overall cultural acceptance (Cook and Reuter, 2007) of alcohol use. At the same time, the rates of quit attempts for alcohol use disorders documented in this
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study appear considerably lower than those previously documented for smoking (Rafful et al., 2013). Ongoing public health efforts in antismoking media campaigns (Emery et al., 2012),
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increased public awareness of negative health consequences (Federal Trade Commission., 2003)
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differences in rates of quit attempts.
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and smoking restrictions in public spaces (Pierce et al., 2011) may have contributed to these
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We found that rates of successful quitting attempts among individuals with alcohol use disorders were around 30%. Although these rates are low, they are considerable higher than the 5% successful attempts for quitting smoking (Rafful et al., 2013). These rates are consistent with the higher remission rates from alcohol than nicotine dependence (Lopez-Quintero et al., 2011a) and may be related to the speed at which physical, psychological and social adverse consequences of alcohol dependence manifest (Chen and Lin, 2009). Given the severe, but often reversible consequences of alcohol use disorders in multiple domains (Alfonso-Loeches and Guerri, 2011; Allen et al., 2011; Rehm et al., 2003, 2009; Roerecke and Rehm, 2012; Rubio et al., 2013; Saarni et al., 2007; Saatcioglu et al., 2008; Samokhvalov et al., 2010) our data identify an important area of opportunity to improve public health.
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10 Consistent with prior studies (Boschloo et al., 2012; Satre et al., 2003; Weisner, 1993; Wilsnack et al., 2000, 2009), we found that male sex, younger age, being single, and having low socioeconomic status increased the odds of attempting to quit. Greater social pressure and fewer
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social resources may increase the need and motivation of these individuals to quit substance use (Cunningham et al., 1994; Weisner et al., 2001; Blanco et al., 2013). In addition, comorbidity
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with other drug and psychiatric disorders further increased the odds of quit attempts. Awareness
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of accumulating harms effect (Orford et al., 2006, 2009), distress (Cunningham et al., 1995; Sobell et al., 1993), and social pressure (George and Tucker, 1996; Hasin, 1994) may act as
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potential triggers for attempting to quit among individuals with alcohol use disorders.
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Our study found that being a female, married and older than 40 years of age increased the odds of successful quit attempts, whereas greater severity of alcohol use disorders and greater
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number of comorbid disorders, including other drug use disorders, decreased the odds of
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successful attempts. The demands of more consolidated adult roles and responsibilities as well as
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increased social support may contribute to explaining the protective effect of certain demographic characteristics (Bjork et al., 2008; Karlamangla et al., 2006). By contrast, more severe psychopathology, including substance-related psychopathology (Blanco et al., 2013b; Koob and Volkow, 2009; Lopez-Quintero et al., 2011a, 2011b; Marlowe et al., 1997; Schmidt and Sander, 2000; Thomas et al., 1999) may promote the use of maladaptive coping skills (Dolan et al., 2013; McNally et al., 2003; Wedekind et al., 2013; Blanco et al., 2014) and result in a reduction of the ability to quit. More generally, the results of study suggest that variables that increase the likelihood of attempts paradoxically tend to predict the failure of those attempts. Factors that may motivate individuals to quit (such as greater symptom severity, greater psychopathology or lower psychosocial support) may reflect greater objective or subjective need
Page 10 of 24
11 to stop substance use, but also lower the ability to muster the resources to attain or maintain abstinence (Secades-Villa et al., 2013). Approaches that seek to decrease the prevalence of alcohol use disorders should consider the paradoxical effects of these factors.
ip t
This study has some limitations. First, the NESARC did not collect information about the
cr
reasons for quitting, which may be important predictors of success. Second, information of
alcohol abuse and dependence was based on self-report and not confirmed by objective methods.
us
Third, the sample was restricted to individuals 18 and older. Our findings may not generalize to
an
younger individuals.
Although alcohol abuse and dependence are highly disabling disorders, rates of attempt
M
to quit are extremely low and among those who attempt to quit only about a third succeed. Several sociodemographic and clinical characteristics predict quit attempts, but among those
d
attempt to quit many of those characteristics predict unsuccessful attempts, probably indicating
te
that those with greatest need and motivation to quit maybe also those with more difficulty
Ac ce p
quitting. We hope this information may be useful for the development of more targeted and effective interventions for alcohol use disorders.
Page 11 of 24
12
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Author Disclosures
Role of Funding Sources Funding for this study was provided in parts by NIH grants DA019606, DA023200, CA133050 and the New York State Psychiatric Institute (Dr. Blanco). The NIH and the NYSPI had no further role in the study design, collection, analysis or interpretation of the data, the writing of the manuscript or the decision to submit the paper for publication.
Ac
ce pt
ed
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an
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Conflict of Interest All the authors declare that they have no conflicts of interest.
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Contributors Carlos Blanco designed the study. Viviana Chiappetta and Roberto Secades-Villa provided summaries of previous research. Chelsea J. Jin undertook the statistical analysis and Viviana Chiappetta and Olaya García-Rodríguez wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Page 20 of 24
Table
1 Table 1. Characteristics of individuals with alcohol abuse with and without attempts to quit in a 3-year period. Wave 1 NESARC 2001-2002 (n = 3,164).
73.23 26.77
2188 623
248 105
71.75 28.25
1636 1175
197 156
56.62 43.38
129 224
95% CI
p-value
1.00 2.28
1.00 1.73
1.00 3.01
N/A =High school Alcohol use Alcohol daily use b Age at first use
No attempts to quit (n = 548) n %a/mean
cr
Attempts to quit (n = 108) n %a/mean
ip t
Table 3. Characteristics of individuals with alcohol dependence with and without attempts to quit in a 3year period. Wave 1 NESARC 2001-2002 (n = 656).
OR
95% CI
p-value
76.37 23.63
426 122
83.87 16.13
1.00 1.61
1.00 0.93
1.00 2.78
N/A 0.0870
65 43
64.66 35.34
301 247
61.5 38.5
1.00 0.87
1.00 0.49
1.00 1.54
N/A 0.6354
87.08 12.92
377 171
71.61 28.39
2.67 1.00
1.54 1.00
4.63 1.00
0.0007 N/A
60.47 39.53
207 341
39.6 60.4
1.00 0.43
1.00 0.25
1.00 0.72
N/A 0.0018
36 72
33.27 66.73
262 286
54.04 45.96
1.00 2.36
1.00 1.39
1.00 4.01
N/A 0.0020
9 99
6.5 93.5
42 506
7.18 92.82
0.90 1.00
0.37 1.00
2.20 1.00
0.8129 N/A
16 107 108
12.84 21.47 2.55
39 543 548
7.62 21.44 1.25
1.79 1.00 1.55
0.85 0.98 1.34
3.77 1.03 1.81
0.1256 0.9615 =High school Alcohol use Alcohol daily use b Age at first use
No attempts to quit (n = 548) n %a/mean
cr
Attempts to quit (n = 108) n %a/mean
ip t
Table 3. Characteristics of individuals with alcohol dependence with and without attempts to quit in a 3year period. Wave 1 NESARC 2001-2002 (n = 656).
OR
95% CI
p-value
76.37 23.63
426 122
83.87 16.13
1.00 1.61
1.00 0.93
1.00 2.78
N/A 0.0870
65 43
64.66 35.34
301 247
61.5 38.5
1.00 0.87
1.00 0.49
1.00 1.54
N/A 0.6354
87.08 12.92
377 171
71.61 28.39
2.67 1.00
1.54 1.00
4.63 1.00
0.0007 N/A
60.47 39.53
207 341
39.6 60.4
1.00 0.43
1.00 0.25
1.00 0.72
N/A 0.0018
36 72
33.27 66.73
262 286
54.04 45.96
1.00 2.36
1.00 1.39
1.00 4.01
N/A 0.0020
9 99
6.5 93.5
42 506
7.18 92.82
0.90 1.00
0.37 1.00
2.20 1.00
0.8129 N/A
16 107 108
12.84 21.47 2.55
39 543 548
7.62 21.44 1.25
1.79 1.00 1.55
0.85 0.98 1.34
3.77 1.03 1.81
0.1256 0.9615
