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Efforts to Quit Smoking Among Persons With a History of Alcohol
Problems -- Iowa, Kansas, and Nebraska, 1995-1996
In 1991, approximately 13.8 million adults in the United
States met diagnostic criteria for alcohol abuse, alcohol
dependence, or both (1). In addition, at least 80% of persons in
this group were likely to be daily tobacco smokers and, therefore,
at increased risk for oral and pharyngeal cancers (2,3). In
Minnesota, among adult smokers with a history of alcohol abuse
during 1972-1983, the number of tobacco-related deaths was higher
than the number of alcohol-related deaths (4). To assess rates of
smoking cessation among adults with a history of alcohol problems,
the University of Nebraska Medical Center conducted an intervention
study with 1 year of follow-up during 1995-1996 in 12 residential
alcohol-treatment centers in Iowa, Kansas, and Nebraska. This
report summarizes the findings, which suggest that a substantial
proportion of adults recently treated for alcoholism attempted to
quit smoking, even though actual quit rates were low.
All participants (n=575) were daily tobacco smokers who
voluntarily enrolled in the study while undergoing residential
treatment for alcohol abuse. Of these 575 persons, 288 (50%) were
receiving care at six alcohol-treatment centers testing a brief
smoking-cessation intervention for recovering alcoholics. The
intervention consisted of four 10-minute individually tailored
counseling discussions about quitting smoking (3,5).
Nicotine-replacement products were not provided. The remaining 287
participants received alcohol treatment at six other centers but
not the additional counseling discussions about quitting smoking.
Characteristics of participants in the centers that provided
smoking-cessation counseling and those that provided only usual
care were similar in age, sex, race/ethnicity, and drug-abuse
history. Overall, 67% of the participants were male, and the
overall mean age was 33 years. Approximately 33% of the
participants self-identified as racial minorities, including 121
American Indians/Alaskan Natives who were clients at the two
centers that served only persons who were American Indian/Alaskan
Native. During the 30 days preceding admission for treatment,
participants reported drinking a mean of 12 alcoholic drinks per
day. The average number of days in residential treatment before
discharge to outpatient care was 34. The mean number of cigarettes
smoked per day was 20 (range: 1-80 cigarettes).
At 1, 6, and 12 months after discharge from residential
treatment, participants completed a mail survey about their recent
drug use that included 10 questions about tobacco. The survey asked
about attempts to quit smoking since the previous assessment and
the number of days of nonsmoking; 1 day was defined as "at least 24
hours." Saliva samples were obtained from and analyzed for cotinine
for the 70% of persons who reported they no longer smoked. For a
randomly selected subset of 176 (33%) of all respondents, a friend
or relative named by the participant at study enrollment was
interviewed by telephone to confirm questionnaire data. At least
one follow-up survey was completed by most (540 {94%})
participants; the 12-month questionnaire was completed by 448
(78%). In this analysis, a successful quitter was defined as a
person who reported at the 12-month follow-up no longer smoking and
not having smoked a cigarette for at least the preceding 7 days.
Of the participants who completed the 12-month follow-up, 36
(8%) reported being successful quitters; of these persons, 29 (80%)
reported not having smoked a cigarette for at least the preceding
30 days. Analysis of cotinine scores of successful quitters
indicated that most (88%) saliva samples had nondetectable cotinine
levels; 12% had been obtained from participants who relapsed to
smoking after completing their questionnaire or who had detectable
levels below the cut-point, suggesting recent tobacco use. Data
from friends and relatives confirmed 165 (94%) of 176 participant
drug-use reports. Quit rates for participants from the centers
providing the smoking-cessation counseling were similar to those of
participants from centers providing usual care (9% compared with
7%, respectively; p greater than 0.05). Sex-specific quit rates
were 9% for males and 6% for females (p greater than 0.05). Rates
for other subgroups were not meaningful because of small sample
sizes.
When quit attempts were analyzed without consideration of
tobacco smoking status at the 12-month assessment, the rates were
higher. For these analyses, unsuccessful quitters (i.e., persons
who had quit smoking but had relapsed back to tobacco smoking by
follow-up) were combined with successful quitters. A quit attempt
of greater than or equal to 24 hours was reported by 45% of the
study sample; 25% of all participants reported quitting for greater
than or equal to 7 days sometime during the year of follow-up
(Table 1). Quit attempt rates for participants from the
smoking-cessation and usual-care treatment centers were similar (p
greater than 0.05).
Race/ethnicity was the only sociodemographic variable
significantly associated with attempts to quit smoking (p less than
0.05). Based on logistic regression models that adjusted for age,
sex, education, and the provision of smoking-cessation counseling,
American Indian/Alaskan Native participants were more likely than
non-Hispanic white participants to report having quit smoking for
greater than or equal to 24 hours and having quit for greater than
or equal to 7 days (Table 2).
Of the participants who reported having quit smoking for
greater than or equal to 7 days by the 12-month follow-up, 73%
reported having relapsed at some time during the preceding year.
Relapse rates were similar by race/ethnicity, age, sex, education,
and provision of smoking-cessation counseling during alcohol
treatment (p greater than 0.05). For example, relapse rates for
non-Hispanic whites, American Indians/Alaskan Natives, and
participants of other racial/ethnic groups were 75%, 68%, and 75%,
respectively.
Reported by: JK Bobo, PhD, Univ of Nebraska Medical Center, Omaha.
Div of Cancer Prevention and Control and Office on Smoking and
Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC. Editorial Note
Editorial Note: The findings in this report suggest that, although
a substantial proportion of clients receiving treatment for alcohol
abuse also were willing to attempt smoking cessation, actual quit
rates were low. Failure of the tobacco intervention to increase
quit rates significantly and high relapse rates among those who
reported quitting for greater than or equal to 7 days probably
reflect the brevity of the smoking-cessation intervention, the
addictive nature of nicotine, and the concurrent challenges of the
other lifestyle changes required for successful recovery from
alcohol abuse (6,7).
Despite restrictions on the sample population in this trial
that limit generalization of the findings, the quit rates in this
study are similar to those reported previously for a nationwide
sample of persons aged greater than or equal to 18 years (8). In
that survey, 42% of daily smokers reported having abstained from
cigarettes for at least 1 day during the preceding year, and 86%
subsequently resumed smoking (8); only 6% of those who were daily
smokers 1 year before the interview quit smoking and maintained
abstinence for at least 1 month. In this study, the finding that
attempts to quit smoking were more common among American
Indian/Alaskan Native participants than among non-Hispanic whites
may reflect the effect of race as a marker for other
sociodemographic characteristics previously associated with tobacco
and smoking cessation (e.g., income, education, occupation, and
community traditions) (9).
In the United States and other countries, recovering
alcoholics have not been encouraged to quit smoking as consistently
as have smokers in the total population because of concerns that
the stress of nicotine withdrawal might provoke a relapse to
alcohol abuse (10). However, this position has not been
substantiated by rigorous trials or investigation (10). In the
study described in this report, recovering alcoholics who were
encouraged to quit smoking were less likely to relapse to drinking
during the 1-year follow-up period (10). Public health departments
can facilitate smoking-cessation efforts among recovering
alcoholics by encouraging community chemical-dependency treatment
programs to routinely screen for and treat tobacco use. The
findings in this report suggest that more intensive interventions,
similar to those employed for treatment of alcohol problems, may be
needed to markedly increase tobacco smoking-cessation rates among
such groups.
References
Grant BF, Harford TC, Dawson DA, Chou P, Dufour M, Pickering R.
Prevalence of DSM-IV alcohol abuse and dependence. Alcohol
Health
Res World 1994;18:243-8.
Blot WJ, McLaughlin JK, Devesa SS, Fraumeni JF Jr. Cancers of
the oral cavity and pharynx. In: Schottenfeld D, Fraumeni JF
Jr,
eds. Cancer epidemiology and prevention. New York: Oxford
University Press, 1996:666-80.
Leed-Kelly A, Russell KS, Bobo JK, McIlvain H. Feasibility of
smoking cessation counseling by phone with alcohol treatment
center
graduates. J Subs Abuse Tx 1996;13:203-10.
Hurt RD, Offord KP, Croghan IT, et al. Mortality following
inpatient addictions treatment: role of tobacco use in a
community-based cohort. JAMA 1996;275:1097-103.
McIlvain HE, Bobo JK, Leed-Kelly A, Sitorius MA. Practical
steps
to smoking cessation for recovering alcoholics. Am Fam
Physician
(in press).
Jarvik ME, Schneider NG. Nicotine. In: Lowinson JH, Ruis P,
Millman RB, Langrod JG, eds. Substance abuse: a comprehensive
textbook. 2nd ed. Baltimore: Williams & Wilkins, 1992:334-56.
Institute of Medicine. Broadening the base of treatment for
alcohol problems. Washington, DC: National Academy Press, 1990.
CDC. Smoking cessation during previous year among adults --
United
States, 1990 and 1991. MMWR 1993;42:504-7.
CDC. Reducing the health consequences of smoking: 25 years of
progress: a report of the Surgeon General. Rockville, Maryland:
US
Department of Health and Human Services, Public Health Service,
1989; DHHS publication no. (CDC)89-8411.
Bobo JK, McIlvain HE, Lando HA, Walker RD, Leed-Kelly A. Effect
of smoking cessation counseling on recovery from alcoholism:
findings from a randomized community intervention trial.
Addiction
(in press).
Table_1
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TABLE 1. Prevalence estimates of recovering alcoholics who reported tobacco smoking quit attempts of =24 hours >=7 days
---------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------
Received Did not receive Overall Received Did not Overall
intervention intervention (n=575) intervention receive (n=575)
(n=288) (n=287) (n=288) intervention
(n=287)
------------------------------- ----------------------------- ---------------------------- --------------------------- ------------------------- ---------------------------
% (95% CI*) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Age group (yrs)
18-24 55.6 (42.3%-68.9%) 50.9 (37.9%-63.9%) 53.2 (43.9%-62.5%) 35.2 (22.5%-47.9%) 33.3 (15.5%-51.1%) 34.2 (25.4%-43.0%)
25-44 44.0 (37.2%-50.8%) 42.1 (35.3%-48.9%) 43.0 (38.2%-47.8%) 21.3 (15.7%-26.9%) 22.8 (17.0%-28.6%) 22.0 (17.9%-26.0%)
>=45 46.2 (27.1%-65.4%) 50.0 (31.5%-68.5%) 48.1 (34.8%-61.4%) 26.9 ( 9.8%-43.9%) 32.1 (14.8%-49.4%) 29.6 (17.4%-41.8%)
Sex
Male 45.0 (38.1%-51.9%) 41.8 (34.7%-48.9%) 43.5 (38.5%-48.4%) 25.0 (18.9%-31.0%) 25.0 (18.6%-35.8%) 25.0 (20.7%-29.3%)
Female 48.9 (38.4%-59.3%) 49.5 (39.8%-59.2%) 49.2 (42.1%-56.3%) 22.7 (13.9%-31.4%) 27.2 (18.6%-35.8%) 25.1 (18.9%-31.2%)
Education (yrs)
<12 42.4 (29.8%-55.0%) 52.3 (40.1%-64.4%) 47.6 (38.8%-56.4%) 22.0 (11.4%-32.6%) 36.9 (25.2%-48.6%) 29.8 (21.7%-37.9%)
12 43.0 (34.6%-51.3%) 40.7 (32.4%-48.9%) 41.9 (36.0%-47.8%) 20.7 (13.9%-27.5%) 20.0 (13.2%-26.7%) 20.4 (15.6%-25.2%)
>12 53.2 (43.1%-63.3%) 45.3 (34.8%-55.8%) 49.4 (42.1%-56.7%) 30.9 (21.6%-40.2%) 26.7 (17.3%-36.0%) 28.9 (22.2%-35.5%)
Race/Ethnicity+
White 41.1 (34.1%-48.0%) 38.2 (31.3%-45.1%) 39.7 (34.8%-44.6%) 20.3 (14.6%-25.9%) 22.0 (16.1%-27.9%) 21.2 (17.0%-25.2%)
American Indian/ 65.6 (53.7%-77.5%) 66.7 (54.8%-78.6%) 66.1 (57.7%-74.5%) 42.6 (30.2%-55.0%) 40.0 (27.6%-52.3%) 41.3 (32.5%-50.1%)
Alaskan Native
Other 40.0 (23.8%-56.2%) 41.7 (25.6%-57.8%) 40.8 (29.3%-52.2%) 14.3 ( 2.7%-25.9%) 22.2 ( 8.6%-35.8%) 18.3 ( 9.3%-27.3%)
Total 46.2 (40.4%-51.9%) 44.6 (38.8%-50.4%) 45.4 (41.3%-49.5%) 24.3 (19.3%-29.2%) 25.8 (20.7%-30.9%) 25.0 (21.5%-28.5%)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Confidence interval.
+ Numbers for other racial/ethnic groups were too small for meaningful analysis.
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Table_2
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TABLE 2. Adjusted odds ratios (AORs)* for tobacco smoking quit attempts of >=24 hours and >=7 days
among recovering alcoholics during 1 year of follow-up after discharge from a residential
alcohol-treatment center -- Iowa, Kansas, and Nebraska, 1995-1996*
====================================================================================================
Quit for >=24 Quit for >=7
hours days
----------------------- -----------------------
Characteristic AOR (95% CI&) AOR (95% CI)
----------------------------------------------------------------------------------------------------
Age group (yrs)
18-24 1.0 Referent 1.0 Referent
25-44 0.8 (0.5-1.2) 0.6 (0.4-1.0)
>=45 1.0 (0.5-1.9) 0.9 (0.4-1.9)
Sex
Male 1.0 Referent 1.0 Referent
Female 1.1 (0.7-1.6) 0.8 (0.5-1.3)
Education (yrs)
<12 1.0 Referent 1.0 Referent
12 0.9 (0.6-1.5) 0.7 (0.4-1.2)
>12 1.4 (0.9-2.3) 1.3 (0.7-2.2)
Race/Ethnicity
White,non-Hispanic 1.0 Referent 1.0 Referent
American Indian/ Alaskan 3.0 (1.9-4.7) 2.7 (1.7-4.3)
Native
Other@ 1.1 (0.7-1.9) 0.9 (0.5-1.8)
----------------------------------------------------------------------------------------------------
* The odds ratios presented for each sociodemographic variable are adjusted for the other
sociodemographic variables in the table and for receipt of the smoking cessation intervention.
+ n=575
& Confidence interval.
@ Four respondents indicated Hispanic ethnicity. These persons were included in the "other" category.
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