Addictive Behu~Gws, Vol. 12, pp. 209-215, 1987 Printed in the USA. All rights reserved.

0306-4603187 $3.00 + .OO Copyright tj 1987 Pergamon Journals Ltd

CIGARETTE SMOKING CESSATION ATTEMPTS BY RECOVERING ALCOHOLICS

JANET KAY BOBO, LEWAYNE D. GILCHRIST, ROBERT F. SCHILLING It, BRENDA NOACH, and STEVEN PAUL SCHINKE

University of Washington

Abstract - Survey data on the smoking cessation experiences of 77 recovering alcoholics are reported. A comparison of successful and unsuccessful quitters addressed questions about optimal timing of cessation efforts, relative severity of alcohol and tobacco abuse histories, and the impact of cessation efforts on the maintenance of sobriety. Findings suggest that recovering alcoholics can successfully quit smoking without jeopardizing so- briety but that individuals with more severe substance abuse histories may be less successful. Although successful quitters tended to wait longer before attempting cessation, a compari- son of the two groups was not statistically significant.

The majority of adults with a history of alcohol abuse are current or former cigarette smokers. Surveys of this population indicate smoking rates exceeding 90% (Ayers, Ruff, & Templer, 1976; Dreher & Fraser, 1967; Maletsky & Klotter, 1974). So commonly linked are the two behaviors that Walton (1972) suggests that non- cigarette smoking alcoholics represent a unique group of substance abusing adults. Since estimates of alcoholism in the U.S. range from seven to ten percent (Noble, 1978), it seems clear that recovering alcoholics are a substantial subset of those at risk for the deleterious effects of tobacco consumption.

The health risks for this subset may even exceed those identified for the general population of smokers. Laboratory and epidemiological studies suggest a synergistic tobacco-alcohol interaction leading to greatly elevated cancer risk (Day & Munoz, 1982; Noble, 1978; U.S. Department of Health and Human Services, 1982). Cigarette smokers who are heavy social drinkers may also be vulnerable (Flanders & Rothman, 1982).

Despite ample documentation of the frequency of concurrent tobacco and alcohol consumption and knowledge of the concomitant health risks, alcohol-involved smokers have received scant research attention to date (Bobo & Gilchrist, 1983; Istvan & Matarazzo, 1984). One series of innovative laboratory studies documented an increase in cigarette smoking during alcohol consumption for problem drinkers (Griffiths, Bigelow, & Liebson, 1976). Another longitudinal study of problem drink- ers who had completed alcohol treatment found that smoking cessation was associ- ated with successful control or cessation of alcohol use (Miller, Hedrick, & Taylor, 1983). Although these reports suggest interactions between drinking and smoking behavior patterns, research on the smoking cessation experiences of recovering alcoholics has not yet been reported in the literature.

Research on this population may yield multiple benefits. Careful study of individ-

Support for this study was provided by Institutional Cancer Grant IN-264 from the American Cancer Society.

Reprint requests should be sent to Janet Kay Bobo, Department of Epidemiology, University of Wash- ington SC-36, Seattle, WA 98195.

209

210 J.K. BOB0 et al.

uals with dual substance abuse histories could lead to new insights on the general phenomena of chemical dependency. Empirical data may guide interventive efforts of professionals - alcoholism counselors, health care workers, staff in smoking cessa- tion clinics - working with alcoholics who want to quit smoking. Such data is essen- tial. Treatment techniques that overlook unique characteristics of the targeted group may be ineffective or counterproductive (Dawley, Carrol, & Morrison, 1980). As effective cessation strategies emerge from exploratory research, substantial health expenditure savings may accrue.

Three broadly-framed questions are of interest. First, does the timing of the smok- ing cessation attempt matter? Should the recovering alcoholic try to quit smoking immediately after regaining control of his or her drinking, or only after a certain period of sustained abstinence ? Second, are recovering alcoholics with relatively more severe alcohol and tobacco use histories less likely to successfully quit smok- ing than those with more moderate experiences? And finally, do smoking cessation efforts tend to have any impact on the maintenance of alcohol abstinence? The study reported here addressed these questions with a comparison of successful and unsuc- cessful cigarette quitters in a sample of adult male graduates of intensive, inpatient

alcohol treatment (IAT) programs.

METHOD

Seventy-seven adult males’ provided data for the study. To guard against the inclusion of subjects nonrepresentative of the group of interest, two steps were taken. A brief screening interview informed potential subjects that only IAT graduates who (a) had maintained sobriety for at least the past six months; (b) had a history of heavy cigarette smoking (minimum of one pack per day for at least one year); and (c) had made at least one “serious” attempt to quit smoking since IAT were eligible to participate. Interested subjects who felt they met these criteria were then required to provide in writing the names, addresses, and phone numbers of two individuals able to verify in a general way the subject’s alcohol and tobacco use histories.

Participants were recruited throughout the Seattle metropolitan area. A single press release in the city’s major newspaper resulted in a deluge of phone calls. Over 200 individuals (97% male) responded the first morning. Although respondents were offered $15.00 for their participation, it was clear that the survey topic tapped a strong current of interest. Some callers refused compensation, urging the inves- tigators to use their payment to include additional subjects. A consent form and a Verifier Information Form were mailed to the first 90 qualified respondents. The first 80 who returned both forms were scheduled for telephone interviews. Twelve per- cent of the final sample were randomly selected for verification. In all cases, inform- ants validated experiences reported by subjects.

Interviews were conducted by phone. Comparisons of in-person and telephone

lWashington state treatment center statistics indicated a 20: I ratio of male to female clients (Washington state bureau of alcohol and substance abuse, 1980). Since the anticipated sample size was small (N = 50) it seemed advisable to limit subject heterogeneity by excluding females. Future studies need to address this limitation.

Cessation attempts 211

interviewing have found the latter an efficient, cost effective, and reliable approach to data collection (Aneshensel, Frerichs, Clark, & Yokopenic, 1982; Dillman, 1978; National Center for Health Services Research, 1977). Most interviews required 30-45 minutes to complete. Every tenth interview was, with the participant’s per- mission, audiotaped. Taped interviews were then used to monitor interviewer con- sistency and scoring accuracy.

Instrument The instrument was patterned after Dillman’s (1978) guidelines for telephone sur-

veys, pilot tested with individuals meeting subject criteria, revised, and repiloted. Alcoholism counselors from local treatment centers further evaluated the instru- ment’s content and relevancy. The final form of the questionnaire contained three segments: (a) a review of the respondent’s alcohol use history, (b) a review of tobacco use history, and (c) demographic descriptors.

Alcohol use history. To obtain a profile of respondent alcohol use history a series of questions assessed onset, intensity, and duration. Each participant reported the approximate month and year in which he (a) started drinking, (b) realized alcohol use was personally harmful, and (c) entered an intensive, inpatient alcohol treatment program. As a cross check on the accuracy of the dates given, interviewers were trained to calculate the respondent’s age (date of birth was obtained early in the interview) at the time of each landmark event and then rephrase key questions using that information (e.g., “How old were you when you first decided you were drinking too much?“) Respondents also reported total number of IAT admissions and drink- ing status since the most recent IAT discharge.

Factor 2 of the Michigan Alcoholism Screening Test (MAST) entitled “Legal, Work, and Social Problems” probed alcoholism severity. The MAST has been widely used in alcoholism research (Gibbs, 1983; Hedlund & Vieweg, 1984). The subscale has a good test-retest reliability (u = .86) (Skinner & Sheu, 1982) and is a cost effective strategy for rapid assessment of alcoholism severity.

Tobacco use history. A related series of questions reconstructed participants’ experiences with cigarette smoking. In addition to obtaining landmark dates, indi- viduals reported the average amount smoked per day. the longest period of tobacco abstinence since IAT, and the number of post-discharge cessation attempts. Finally, three Likert-scaled items assessed respondent perceptions of the impact of smoking cessation efforts on their maintenance of alcohol abstinence.

Demographics. Demographic descriptors included age, race, education, occupa- tion, income level, and marital status.

RESULTS

Sample characteristics Four of the 77 completed interviews were discarded because of conflicting re-

sponses within the questionnaire. The mean age of the remaining 73 respondents was 43 (SD = 11.08). The sample was largely (97%) Caucasian. Sixteen percent of the sample had educational training beyond the bachelors level, 25% had a BA/BS de- gree or a vocational certificate, 59% had a high school education or less. Thirty-eight percent were employed in occupations traditionally labeled as white collar, 40% had blue collar positions, and 22% were students or unemployed. Annual income re-

212

70-

60-

50-

th 40-

s k 2 x

30-

20-

10 -

J.K. BOB0 et al.

i

OO 2 1 4 1 1 I

6 6

Time in years

Fig. I. Lapsed time in years between completion of intensive alcohol treatment and start of most successful smoking cessation attempt.

fleeted the diversity in education and occupation: 20% reported $10,000 or less annual income; 23% between $10- and $20,000; 22% between $20- and $30,000; and 34% reported more than $30,000 income per year. Nearly half of the sample (48%) was married, 23% divorced, and 29% never married.

Alcohol ust’ histories Most respondents started drinking seriously in adolescence or as young adults

(mean age = 19.3, SD = 6.2). Alcohol related problems started for the majority around the age of 30 (x = 29.8, SD = 10.3). Most (70%) respondents reported only one IAT admission. Of the 22 participants reporting two or more admissions, nine percent had been treated at least four times. Mean number of years since discharge from the most recent IAT was 4.4 years (SD = 3.5). When asked about the extent of post-discharge drinking, 71% indicated complete abstinence, 5% admitted to “a few drinks,” 14% reported one day of heavy drinking, and 10% reported intermittent heavy drinking. All subjects, though, reported uninterrupted sobriety for the six months preceding the interview.

Using Skinner’s (1982) unweighted scoring scheme (No = 0, Yes = l), the MAST subscale score was computed for each subject. The sample mean was 4.76 (SD = 1.52). A score of 6 or more was obtained for 41% of the respondents. A score of 7 indicated that the respondent had experienced all of the listed negative sequelae of heavy drinking (e.g., getting into fights, losing a job because of drinking, etc.).

Tobuctw usr histories Most respondents reported that they started smoking regularly several years prior

Cessation attempts 213

Table 1. Severity comparisons for alcohol and tobacco use histories.

Group Means

Variable

Successful Quitters

(N = 14)

Unsuccessful Quitters

(N = 53) p value”

Alcohol Use History

Number of Intensive Alcohol Treatment Admission

Number of years with alcohol-related problems at most successful smoking cessation attempt

MAST subscale score

Tobacco Use History

Tobacco consumption during Intensive Alcohol Treatment

Number of smoking-related health problems

Number of years with tobacco dependency at most successful attempt

1.28 1.73 .05

10.28 11.49 NS

4.71 4.77 NS

5.93 6.60 ,001

1.07 1.69 .I0

25.75 24.78 NS

dRewlting from Z-sample, 2-tailed t-test comparisons.

to the onset of steady drinking. The mean age when daily smoking began was 16.2 years (SD = 3.9). When asked about the average amount smoked on a daily basis, 88% reported more than one pack per day. Similarly, 96% reported smoking at least that much when they entered the most recent - or only - alcohol treatment program. Since discharge from that program, 32% had made one “serious” attempt to quit smoking, another 30% had tried twice, while the rest had made three or more at- tempts.

Responses to several items classified subjects as successful or unsuccessful ciga- rette quitters. The beginning and, if appropriate, ending month of each respondent’s most successful post-IAT cessation attempt were noted. Subjects also reported the day, month, and year of their most recent cigarette. Seventy-three percent of the sample (N = 53) were current smokers at the time of the survey and had no previous cessation periods exceeding two months in duration. These subjects were classified as unsuccessful quitters. Nineteen percent of the sample (N = 14) had not smoked for a minimum of six months and were labeled as successful quitters. Twelve of the successes had been tobacco abstinent for more than a year. The remaining six cases (eight percent) were current nonsmokers with between two and six months of tobacco abstinence. They were labeled as “unclear” and excluded from analyses comparing successful and unsuccessful quitters.

Timing of cessation attempt The amount of lapsed time between the beginning of the longest period of tobacco

abstinence since IAT and discharge from that treatment program was calculated for each subject. That data, collapsed to years, is presented in Fig. 1. Mean lapsed time, in months, for successful quitters was 36.21 (SD = 31.83); for unsuccessful quitters, 28.62 months (SD = 31.89). This difference was not statistically significant at the .05

214 J.K. BOB0 et al.

Table 2. Respondent perceptions of the impact of tobacco cessation efforts on the maintenance of sobriety.

Items % Agree % Disagree (h’= 73) (N-73)

When I firct quit smoking. 1 really wanted to drink again.

13.7 86.3

Trying to avoid cigarettes has caused me to drink alcohol.

5,s 94.5

Sometimes I am afraid that if I don’t have a smoke. 1 will have a drink instead.

16.4 83.6

level (t = 1.04). Of note is the fact that 24.6% of the total sample started their most

successful (i.e., longest) cessation attempt within six-months of completing treat- ment .

Successful and unsuccessful quitters were compared on six variables: three compo- nents of their alcoholism history and three components of their cigarette smoking history. Table I summarizes the resuhs of these comparisons. Response options for the item entitled “Tobacco consumption during IAT” ranged from a high score of 8, indicating 3 or more packs of cigarettes per day, to a low of 1, indicating no smoking at all during treatment.

The data suggest that recovering alcoholics with relatively less severe substance use histories are more likely to be successful in their attempts to quit smoking. In contrast to unsuccessful quitters, successful quitters had (a) fewer IAT admissions, (b) lower MAST subscale scores, (c) briefer alcohol-but not tobacco-abuse his- tories, (d) fewer health problems from smoking, and (e) lower smoking rates during IAT.

The impact of tobacco cessation efforts on the maintenance of sobriety was exam- ined in two ways. Table 2 summarizes respondent perceptions of the impact of their efforts to quit smoking. Note that the four Likert-scaled response options have been collapsed to three for the table. Although all successful quitters strongly disagreed with questions 2 and 3, chi square comparisons were non-significant at the .05 level. The amount of reported drinking since IAT was also compared. Almost all (93%) of the successful quitters reported uninterrupted sobriety since discharge; one respon- dent reported one day of heavy drinking. By contrast, 13% of the unsuccessful quitters reported two or more periods of heavy drinking. A chi square comparison of the two groups was not statistically significant.

DISCUSSION

Before summarizing the findings of this preliminary study, its limitations should be noted. The sample was small and self-selected. Self-report data should be interpreted with some caution. Volunteer participants may differ in some substantial way from the general population of recovering alcoholics. Findings may not be at all applicable to women and ethnic minority persons.

Cessation attempts 215

Within these limitations, several tentative conclusions can be drawn from this pilot data. Cigarette smokers with a history of alcohol abuse can successfully quit smok- ing without jeopardizing the maintenance of their sobriety. However, recovering alcoholics with a high MAST subscale score, multiple IAT admissions, heavy smok- ing during alcohol treatment, and numerous tobacco-related health problems may find tobacco abstinence an elusive goal. The data further suggest that although smoking cessation efforts appear to be common during the Iirst six months after completion of IAT, later efforts may be more successful.

These findings should be confirmed with replication studies. Longitudinal evalua- tion of the smoking cessation experiences of a large sample of IAT graduates over a five-year period is needed. Also needed are controlled comparisons of professionally-directed and self-help only cessation efforts among recovering alco- holics. Perhaps the heuristic findings reported here will precipitate further research on the smoking cessation experiences of recovering alcoholics.

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