relapse is considerable (reviewed by Brandon, ..... smoking relapse episodes (Brandon, Tiffany & .... BRYANT, A. (1986) Cigarette withdrawal symptoms in.
British Journal of Addiction (1990) 85, 263-269
CONFERENCE REPORT
Alcohol or tobacco research versus alcohol and tobacco research LINDA C. SOBELL,i'2'3 MARK B. , LYNN T. KOZLOWSKIi'2'4 & TONY TONEATTO' ^Clinical Institute, Addiction Research Foundation, 33 Russell Street, Toronto, Ontario M5S 2S1, ^Department of Psychology, ^Department of Behavioural Science and ^Department of Preventive Medicine and Biostatistics, University of Toronto, Canada
Summary Despite the frequent co-occurrence of tobacco and alcohol use, little is known about relationships between alcohol and nicotine. This paper reviews similarities and differences between tobacco and alcohol use, offers speculation about why a marriage of the two fields has been so long in coming, and discusses the multiple scientific and therapeutic benefits that could derive from the study of individuals who use both drugs.
Introduction Nearly 90 years ago, Dabbs, a physician writing in this journal (then called the British Journal of Inebriety), tried to account for his failure to help three men with 'inveterate alcoholic inebriety' who were later successfully treated by the Salvation Army. He stated that he had come to agree with the three men that "the prohibition of tobacco by the 'Army' was exactly the vital prohibition omitted by me". As one of the recovered inebriates stated: You did yer best, but you was 'alf-'arted. You felt you could give up yer drink, but you couldn't give up yer baccy, and so you let me 'ave mine. Once take too much drink and any bacca at all will make you go to it again, (p. 78) While Dabbs conceded that it might "be true that Reprint requests to: Dr L. Sobell. * While this paper is focused on alcohol and tobacco, we recognize that the addiction field must attend to multiple substance use and abuse. This point is supported by the fact that multiple drug use is now the rule rather than the exception among alcohol and drug abusers (reviewed in Sobell, Sobell & Nirenberg, 1988).
in vetoing alcohol we must also veto tobacco", this suggestion did not trigger a revolution in the treatment of alcohol problems. Even the Salvation Army's treatment programs have not uniformly, if at all, continued the proscription against tobacco use. Alcohol and nicotine use and abuse are related phenomena, but their concurrent use has received little study. In this paper, we assert that alcohol and tobacco researchers have much to gain from better understanding each other's field, and that important clinical research advances could result from the cross fertilization of these two fields.* The available evidence, much of which will be reviewed here, makes us hopeful that our suggestions will meet with a more favorable response than occurred for Dr Dabbs.
Compelling facts As drugs of abuse, alcohol and tobacco share many features. First, after stopping drug use, the risk of
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relapse is considerable (reviewed by Brandon, Tiffany & Baker, 1986; Sobell, Sobell & Nirenberg, 1988). Second, the vast majority of individuals who abuse alcohol or nicotine do not come to the attention of researchers or clinicians. Compared to formal treatment, self-change or natural recoveries account for a high percentage of recoveries (reviewed in DiClemente & Prochaska, 1982; Fillmore, 1988; Stall & Bienacki, 1986; US Department of Health and Human Services, 1988). Third, alcohol and nicotine abusers who recover without formal interventions exhibit fewer problems and less dependence than those who enter treatment programs (Fillmore, 1988; US Department of Health and Human Services, 1982; US Department of Health and Human Services, 1986). Fourth, the health hazards and mortality rates associated with either smoking or excessive drinking are considerable, and when both drugs are used concurrently the risk of various diseases increases synergistically (Klatsky et al., 1983; Luce & Schweitzer, 1978; US Department of Health and Human Services, 1982; Kozlowski & Ferrence, pp. 271-278—in this issue of BJA). Despite this, it is often difficult to convince individuals to stop using these drugs because the major health risks related to both alcohol abuse (e.g. cirrhosis, hepatic and cognitive dysfunction) and tobacco abuse (e.g. chronic disease effects) are longterm effects. Fifth, there seems to be an inverse relationship between heaviness of smoking or drinking and recov ery rate (Ockene, 1984; Sobell & Sobell, 1989; Wilcox etal, 1985). Sixth, aclear dose gradient relationship exists between these two drugs, suggesting that common processes may underlie their use (e.g. conditioning factors common to the maintenance of both behaviors). Theoretically, therefore, the study of individuals with dual substance abuse histories could lead to a better understanding of the general phenomena of substance use and misuse. Seventh, from a public policy and health promotion standpoint, both alcohol and tobacco are heavily used, widely advertised in the print medium, and are legally and commercially available substances, the production of which is tied in no small way to national economies and to government tax bases. The relationship between tobacco and alcohol abuse appears ubiquitous in Western Society. Almost all studies that have examined the prevalence of smoking among alcohol abusers have found that between 80 to 95% of all alcohol abusers also smoke cigarettes (Bobo et al., 1987; Burling & Ziff, 1988; Istvan & Matarazzo, 1984; Kozlowski, Jellinek & Pope, 1986; Taylor & Taylor, 1984; US Department
of Health and Human Services, 1986), whereas only about 30% of the adult population smoke cigarettes (Ferrence, 1988; Harris, 1983; Remington et al., 1985). Thus, alcohol abusers typically are smokers. Despite the high co-occurrence of alcohol and tobacco use, the relationship between quitting smoking and quitting drinking has been relatively unexplored (Battjes, 1988; Burling & Ziff, 1988). Until recently, there were no published research reports on the smoking cessation experiences of recovering alcoholics (Bobo et al., 1987), and there still are no published reports of clinical trials comparing the effectiveness of concurrent versus sequenced treatments for individuals addicted to both alcohol and nicotine. In light of the many commonalities among alcohol and tobacco use, it is curious why their interrelationship has failed to attract much research attention. Two possible factors deserve brief mention. First, whereas excessive drinking has long been recognized as a health problem for which treatment is appropriate, until recently, cigarettes have been used with widespread social approval. In fact, consideration of nicotine as a substance use disorder by the American Psychiatric Association only occurred in 1980 (American Psychiatric Association, 1980). Today, however, this has changed. Smoking is increasingly being viewed as deviant (only a minority still smoke cigarettes), as drug use, and has officially been proclaimed an addictive drug with extreme abuse potential and serious health consequences (US Department of Health and Human Services, 1988). Despite these changes, though, nicotine dependence is rarely recognized as a reimbursable clinical disorder by insurance companies or Medicare in the United States (Slade, 1987). A second possible reason for the estrangement between the alcohol and tobacco fields relates to 'clinical folk wisdom', which has long held that alcohol abuse should be treated before tackling tobacco use (Bobo & Gilchrist, 1983; Kozlowski et al, 1989a; Miller, Hedrick & Taylor, 1983). The concern is that simultaneous quitting might increase the risk of relapse to drinking. However, since the necessary clinical trials have never been undertaken, this position lacks empirical support.
Similar, yes! twins, no! Despite their multiple similarities, alcohol and nicotine differ in many respects. The most notable include the following. First, evidence for progres-
Alcohol or tobacco research sivity is strongest for nicotine, in that individuals who smoke only a few cigarettes are very likely to become heavier smokers (Krasnegor & Renault, 1979; Russell, 1976; Salber & Abeline, 1967). In contrast, the majority of those who use alcohol do not become abusers (Cahalan, Cisin & Crossley, 1969). Second, the time-course of the development of physical dependence on alcohol and nicotine differs considerably. While physical dependence on nicotine can develop relatively quickly (e.g. within a year, an individual may be smoking more than 20 cigarettes per day and undergo a withdrawal syndrome upon stopping; McNeill et al., 1986), clinically significant physical dependence on alcohol may take several years to develop (Mandell, 1983). Third, the prevalence rates for cigarette smoking are two or three times as high as those for alcohol abuse. Currently, about 30% of the adult population smokes cigarettes (Ferrence, 1988; Harris, 1983; Remington et al., 1985), whereas from 7 to 15% of the adult population has drinking problems (American Psychiatric Association, 1987; Cahalan, 1970; Fillmore, 1988; National Institute on Alcohol Abuse and Alcoholism, 1987). A fourth difference between the two substances relates to resultant consequences when the substances are used in moderation and to treatment goal selection for abusers. While nicotine is considered dangerous to health at all levels of use, with a strong dose response effect (Kozlowski, 1989; US Department of Health and Human Services, 1986), consumption of small amounts of alcohol does not appear harmful for most individuals (Thornton, Symes & Heaton, 1983; Turner, Mezey & Kimball, 1977). Related to this, most treatment programs for cigarette smokers promote abstinence as a goal (Sobell, Toneatto & Sobell, in press); US Department of Health and Human Services, 1988). In addition to health risks associated with low doses, there are two major reasons for an abstinence goal. First, nicotine use incurs substantial potential for dependency (sustained limited use of cigarettes is uncommon—fewer than 10% of smokers smoke < 1 0 cigarettes per day (Russell, 1976; US Department of Health and Human Services, 1988). Second, individuals who smoke a few cigarettes per day can adjust their puff and inhalation rates to obtain high nicotine and tar levels (i.e. exposure to nicotine and tar is not necessarily a direct function of the number of cigarettes smoked; Benowitz et al, 1983; Kozlowski, 1981). Despite considerable controversy (see Sobell & Sobell, 1987b) there is considerable empirical sup-
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port for the viability of a reduced consumption goal for alcohol abusers, especially those who are not severely dependent on alcohol (Heather & Robertson, 1983; Sobell & Sobell, 1987a). Evidence for successful moderation outcomes derives from several lines of research (e.g. controlled clinical trials; treatment outcomes from abstinence goal studies; natural history studies; reviewed in Sobell et al., in press). Finally, in contrast to cigarette use, limited consumption of alcohol is the most common pattern of use. Another possible difference between alcohol and tobacco use involves subjective evaluations of dependence upon the two drugs. In a large survey of clients in treatment for alcohol and drug problems, 57% reported that giving up cigarettes would be more difficult than giving up alcohol or the drug that brought them for treatment. While 43% of the alcohol abusers rated their strongest urge for cigarettes stronger than their strongest urge for alcohol, only 14% said they derived more pleasure from smoking cigarettes than drinking (Kozlowski et al., 1989b).
If you don't ask, you won't know Why is there a notable lack of research examining simultaneous use of alcohol and tobacco? While some may believe that nothing is to be gained, it may simply be that researchers in both fields have not thought of venturing outside their own domains. In this regard, the following example is included to illustrate the potential gains in knowledge that could result from the exploration of the relationship between tobacco and alcohol use. In a major study of natural recoveries (i.e. with no formal treatment) from alcohol problems being conducted by some of the present authors, subjects were interviewed about factors that had helped them maintain their recovery from alcohol problems. Subjects who responded affirmatively were asked to comment on how and why these changes helped. Although the interviews with subjects lasted an average of slightly more than two hours, only one question on tobacco use was asked: "During the first year (after your resolution), did you experience any changes in your smoking habits which helped you avoid a relapse to problem drinking?" Several months into the project it became clear to us that a number of the subjects had also stopped smoking cigarettes. Thus, after reviewing the records for subjects interviewed up to that time, we decided that it would be useful to obtain some
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limited information about tobacco use from subsequently interviewed subjects (subjects already interviewed were recontacted by phone to obtain this information). Since the results of this study are currently being analyzed, only characteristics relevant to the dual cessation of alcohol and tobacco are presented here. The project was based on interviews with recovered subjects (w = 119); most of whom (94%) had resolved a drinking problem for >;3 years and a control group of nonresolved subjects who had alcohol problems (minimum of 5 years), but had never sought or received formal help or treatment prior to the interview. A friend or relative was interviewed to verify each subject's past drinking history, the resolution (for the resolved group), and related reports. Consistent with other studies, the vast majority {Resolved: 90.8%, 109/120; Non-resolved: 91.9%, 57/62) of these subjects had been or were cigarette smokers. Nearly half (48.8%) of all subjects who ever smoked cigarettes had quite smoking by the time they were interviewed. There was, however, a significant difference between the groups in that significantly fewer of the control subjects had quit smoking (20 of 57 cigarette smokers) than the resolved subjects (61 of 109 cigarette smokers) had quit smoking cigarettes (;|j^ = 6.53, /)=0.01, d.f. = l). This finding suggests a possible relationship between quitting smoking and quitting or cutting down drinking. Considering the high relapse rates found across all addictive behaviors, those who have successfully resolved two drug problems are a unique subject population. It also warrants mention that those alcohol abusers who quit smoking had been heavy smokers, who on the average smoked one and a half packs of cigarettes per day for more than two decades prior to quitting. Table 1 shows smoking history variables for the resolved and nonresolved subjects who had stopped smoking cigarettes. There were no significant differences between groups in terms of mean number of years smoked, mean number of cigarettes smoked per day prior to quitting, or number of years quit smoking.
Currently, a 5-year follow-up interview with all eligible subjects is exploring possible relationships between several substances of use and abuse. In particular, factors related to dual resolutions, the temporal ordering of dual resolutions, urges upon cessation of substance use, and the interrelationships of multiple substance use are being probed.
Benefits of combining alcohol and tobacco research One purpose of this paper was to argue that a systematic examination of the relationship between alcohol and tobacco use has practical and scientific value. For example, an understanding of simultaneous and sequential cessation strategies may have important treatment and self-change strategy implications (e.g. based on self-efficacy theory, it could be hypothesized that successfully resolving one substance abuse problem could, by generalization, predict success in dealing with another substance abuse problem). Two studies provide some indirect evidence for this hypothesis. Despite a limited number of subjects. Miller and his colleagues (1983) found that alcohol abusers who had quit smoking prior to treatment, had more successful post-treatment drinking outcomes than alcohol abusers who continued to smoke. In the second study, higher abstinence rates were reported in recovering alcoholics who had successfully quit smoking, as compared to those who continued to smoke (Bobo et al, 1987). Knowing about the relationship between smoking and drinking could also affect clinical interventions. For example, one could identify a population of potential heavy drinkers by identifying a population of heavy smokers (c/. Kozlowski & Ferrence, this volume), and vice-versa. One of the most natural paths for bridging the gap between the alcohol and tobacco fields would be the treatment of individuals who drink alcohol excessively and smoke cigarettes. Recently, close to half (46%) of outpatient alcohol
Table 1. Characteristics of subjects vjho had stopped smoking Group (n)
Resolved (60) Non-resolved (20) "Two-tailed f-tests,/)>0.05.
No. of years smoked"
No. of cigarettes smoked per day°
No. of years quit smoking"
Mean(±SD)
Mean(±SD)
Mean ( ± SD)
23.5 ±12.9 21.5 ±12.9
36.9 ±19.2 30.2 ±14.3
ll.l±10.1 9.6 ±7.4
Alcohol or tobacco research and dmg abusers indicated substantial interest in attending a smoking treatment program if it were available as part of treatment (Kozlowski et al., 1989a). In a more recent survey (Kozlowski, unpublished observations), 25% of all alcohol and dmg abusers («=805) indicated they would be willing to try to quit smoking at the same time as trying to quit using alcohol or the dmg which brought them for help. The results of these two surveys suggest that combined therapies may be attractive to substance abusers who smoke. Since both alcohol and tobacco use often appear during adolescence (Donovan, Jessor & Jessor, 1983; Jessor & Jessor, 1975; Welte & Barnes, 1987), common psychosocial processes (e.g. peer pressure, teenage rebellion, role modelling) may underlie the initiation of these two behaviors. A study of these processes may not only advance our conceptual understanding of how alcohol and tobacco use are acquired but may also suggest more effective and efficient means of developing preventive strategies. Current primary prevention programs typically focus on either alcohol or tobacco use (e.g. see Cellucci, 1984); if the use of both substances is associated with a common set of factors then it may be reasonable to target both behaviors simultaneously in preventive or early intervention programs for adolescents. Several models propose that learned association (conditioned cues) play a major role in precipitating dmg use and relapse. As summarized by Niaura and his colleagues (1988), these models include conditioned withdrawal, conditioned compensatory responding, appetitive motivational, and social leaming models. All models assign a significant role to cue reactivity, which in the present case refers to reactions to cues that have previously been associated with either ethanol or tobacco consumption. A large body of evidence now exists demonstrating such conditioned responses. While the several proposed models differ, and it will be some time before any model emerges that provides a clearly superior explanation for the data, it seems certain that cue reactivity will come to play a major role in explaining substance use and abuse. The considerable overlap of tobacco and alcohol use implies that these behaviors share many cues. Cues that increase the probability of smoking may also tend to make drinking more probable, and viceversa. Since these cues would include those associated with the very act of substance consumption, it may be that attempting to stop using either alcohol or tobacco while maintaining use of the other
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product is more difficult than quitting both substances at the same time. A particularly complex set of issues is likely to arise when one considers the impact that continued smoking may have on attempts to moderate rather than cease alcohol consumption. The main issue needing research attention concerns the ease with which a discrimination between cues can be acquired, such that a cue can be associated with smoking but not associated with heavy drinking. If such a discrimination is slow in forming, it is possible that cues associated with smoking could elicit increased drinking in an individual attempting to drink in moderation. Similarly, for an individual who drinks moderately but has stopped smoking, drinking could serve as a cue for smoking and possibly precipitate a relapse. In fact, two studies have found alcohol to be associated with from one-fifth to almost one-half of all smoking relapse episodes (Brandon, Tiffany & Baker, 1986; Shiffman, 1982). Such results should not be surprising, as several laboratory studies have suggested that alcohol consumption promotes smoking (noted in Shiffman, 1982). Further, alcohol may be only one of several powerful cues that coud elicit a smoking relapse. In one study, 59% of the subjects reported some type of substance use preceding relapse to smoking (food and coffee accounted for a large percentage of those relapses; Shiffman, 1982). Finally, while simultaneous cessation of use of both dmgs has some theoretical support, it could also be that a sequential approach would be effective. For instance. Burling & Ziff (1988) recently suggested that if cessation of tobacco use preceded attempts to deal with alcohol, the person possibly could gain in vivo exposure to techniques for coping with urges, which might make it easier to refrain from drinking. While arguments about the effectiveness of concurrent or sequential cessation strategies are speculative, they are testable.
Conclusions In summary, the dramatically high co-occurrence of heavy drinking and heavy smoking demands serious research attention in terms of etiology, natural history and clinical interventions. Whether the explanation for co-occurrence lies in biological, personality, social learning, or cultural factors, or in a combination of these, it is a highly replicable finding. Explaining this phenomena is also likely to bring us closer to understanding the etiology of, and factors regulating, both heavy drinking and smoking. While there are considerable opportunities for
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research at both a theoretical and practical level, a necessary first step is the recognition by alcohol and tobacco researchers that much could be gained from a shared understanding of these two substances.
study, Canadian Journal of Public Health, 79, pp.
160-165.
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