Journalof Substance Abuse Treatment, Vol. 3, pp. 21-25. 1986 Printed in the USA. All rights resewed.

0740.5472/66 S3.00 + .OO Copyright 0 1986 Pergamon Journals Ltd

ORIGINAL CONTRIBUTION

The Double Triumph: Sustained Sobriety and Successful Cigarette Smoking Cessation

JANET KAY BOBO, MSW, ROBERT F. SCHILLINO, POD, LEWAYNE D. GILCHRIST, POD, AND STEVEN PAUL &XXINKE, PhD

Child Development and Mad Retardation Center University of Washington, Seattle, Washington

Abstract- Conventional practice wisdom has long shielded alcohol treatment center clients from social and medical pressures to quit smoking. But, recent findings of inceased cancer risk are forc- ing a t-e-examination of traditional practices. Lktailed cam h&to* of 14 recovering alcoholics who SuccesTfily quit smoking suggest the feasibility of cessation efforts even in the face of sevem substance abuse h&tories.

Keywords-Alcoholism, smoking, smoking cessation, alcoholism treatment

INTRODUCTION

CONTROVERSY SURROUNDS the subject of cigarette smoking by recovering alcoholics. Are the health risks associated with alcohol abuse so substantial as to completely overshadow those associated with smoking or, are the tobacco consumption habits of alcohol-involved adults of major concern? If ciga- rette smoking is of central importance, should al- cohol treatment specialists ignore or directly address the topic with their clients?

A 1983 survey of 311 alcohol treatment specialists documented the wide disparity in professional opin- ions on these and other issues (Bobo & Gilchrist, 1983). Almost half of the respondents reported never having personally encouraged an alcoholic client to quit smoking. Yet, nearly a third indicated that they wanted a smoking cessation plan developed for al- coholics and incorporated in their treatment center’s program. Treatment specialists also disagreed about whether or not it was more difficult for the “average alcoholic” to quit smoking than for the average non- alcoholic.

Perhaps the most central point of debate con- cerned the potential impact of smoking cessation ef- forts on the maintenance of sobriety. Two respon- dents succinctly framed opposing sentiments with unsolicited comments penned on the back of their questionnaires. One asserted that “Recovering from

Reprint requests should be sent to Janet Kay Bobo at the Child Development and Mental Retardation Center, University of Washington, WJ-10. Seattle, Washington, 98195.

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

alcoholism is extremely stressful, adding more stress, i.e. quitting smoking, would be endangering recov- ery.” The other commented “I think it’s disturbing that we focus on a patient’s recovery from alcohol addiction (sic) and allow them to go on and die from nicotine addiction” (Bobo & Gilchrist, 1983).

This article will address one root of this lack of professional consensus. Although there are other roots-differing personal experiences with drinking and smoking, varying community norms, and di- vergent treatment center policies, a central one is the dearth of relevent information in the treatment litera- ture. The following paragraphs summarize findings reported to date on smoking among alcoholic popu- lations and then detail the experiences of 14 recover- ing alcoholics who successfully quit smoking.

BACKGROUND

Cigarette smoking is, in and of itself, a major health problem. The general risks associated with it are widely recognized and need not be reviewed here (USPHS, 1979). Of central significance though are the empirically supported findings that suggest that concomitant alcohol and tobacco use greatly increase oral and esophageal cancer risk (Memorial Sloan- Kettering Cancer Center, 1982; Noble, 1978; USDHHS, 1982). Many recovering alcoholics relapse to drinking (Marlatt, 1985). Those who have con- tinued to smoke, whether drinking or not, may be at greater health risk during abstinence breaks than was formerly acknowledged. If so, the tobacco consump tion habits of alcoholic clients are of major concern.

Equally important is the finding that the majority of alcoholics and recovering alcoholics are either cur-

21

22 J. K. Bobo et al.

rent or former cigarette smokers. Several studies of alcohol-involved adults have found smoking rates that exceed 90% (Ayers, Ruff, & Templer, 1976; Dreher & Fraser, 1%7; Maletsky BE Klotter, 1974). In the survey of alcohol treatment professionals men- tioned earlier, more than half of the respondents who identified themselves as recovering alcoholics also self-reported current cigarette smoking. By contrast, a recent analysis of smoking within the general popu- lation estimates that about one third of U.S. adults are smokers (Remington, Forman, Gentry, Marks, Hogelin, & Trowbridge, 1985).

Alcohol consumption and tobacco smoking also appear to be correlated for non-alcoholics. An excel- lent review of 28 studies that examined the co-occur- rence of these two behaviors concluded that:

there is a moderately strong relationship between tobacco and alcohol consumption among American adults and adults from other Western developed countries such as Sweden and Australia. Further, to the extent that data on smoking and drinking patterns of women exist, findings suggest that this relationship between smoking and alcohol consumption among adults is of approximately equal mag- nitude in both sexes (Istvan & -0, 1984, p. 310).

Alcohol treatment personnel are not unaware of these findings. Yet, craft reports and empirical stud- ies suggesting smoking cessation strategies for re- covering alcoholics have not surfaced in the litera- ture. This absence of treatment reports may be due, in part, to the lack of published data addressing two preliminary, but fundamental, issues. The fast con- cerns the feasibility of urging the recovering alcoholic with a history of heavy drinking and frequent relapses to curtail both smoking and drinking behaviors. If controlled intake of one substance has been elusive, is control of both even possible? Until affirmative data are available for this initial question, counselors may hesitate to develop or implement therapeutic techniques.

A second issue concerns the impact of smoking cessation efforts on the maintenance of sobriety. Miller, Hedrick, and Taylor (1983) have challenged the traditional assumption that smoking cessation at- tempts during alcohol treatment are counterthera- peutic and increase the risk of relapse. In a two year followup study of problem drinkers who had com- pleted a behavioral self-control treatment program, they found that “smoking cessation was associated with successful control or cessation of alcohol use and relapse to smoking coincided with unremitted drinking” (Miller, Hedrick, & Taylor, 1983, p. 403).

The Miller study did not, however, report on the existence or absence of brief, or extensive, drinking relapses during smoking cessation attempts. Some participants may have relapsed to drinking when they first quit smoking but had both behaviors under con-

trol by final followup. The potential for relapses of this nature is of substantial concern to alcoholism counselors and clients.

Also of concern are questions of timing and tech- nique. Alcoholism counselors have suggested that clients wait a year after completing intensive treat- ment before attempting cigarette smoking cessation (Bob0 & Gilchrist, 1983). Data derived from detailed case histories of recovering alcoholics who have tried to quit smoking may yield different recommenda- tions. Smoking cessation researchers have noted the need to tailor treatment strategies to the unique characteristics of the targeted population (Dawley, Carrol, & Morrison, 1980; Schilling, Gilchrist, & Schinke, 1985). Again, case histories from recovering alcoholics are a logical source for such information.

METHODS

In 1984, the authors conducted a telephone survey of the smoking cessation experiences of 73 self-identi- fied recovering alcoholics. Only adult male graduates of intensive, inpatient alcohol treatment programs who (a) had maintained sobriety for at least the past six months; (b) had a history of heavy cigarette smoking (minimum of 1 pack per day for at least one year); and (c) had made at least one “serious” attempt to quit smoking since discharge from treatment were interviewed. Respondents were recruited from the Seattle metropolitan community with posters and a single newspaper ad. Each participant received $15.00 as compensation for the time involved in a 30 minute telephone interview.

Detailed case histories discriminated successful from unsuccessful cigarette quitters. Successful quit- ters were defined as those who had not smoked for at least the six month period preceding their interview. Nineteen percent of the sample (14 respondents) met this criteria. Results of statistical comparisons of the two groups, successful and unsuccessful quitters, have been reported elsewhere (Bobo, Gilchrist, Schilling, Noach, & Schinke, in press) and will not be reviewed here. The data that follow summarize only the subset of 14 successful quitters.

FINDINGS

Mean age for this largely Caucasian (93?ro) group was 40 years. The youngest respondent was 29, the oldest 64. Half of the group considered themselves white collar employees in occupations such as administra- tion or counseling. Twenty-nine percent held blue collar or service positions. The remaining 21% were in school and/or unemployed. Most (64Vo) were mar- ried. One respondent was divorced; 4 others had never married.

Double Triumph 23

Severity of Substance Abuse Histories

All respondents reported experiencing major deleteri- ous consequences of their drinking. More than half (64Vo) had lost a job. Fifty-seven percent had been arrested for drunk driving. And 36% had experi- enced delirium tremens and/or hallucinations. Like- wise, most mentioned at least one major health prob- lem stemming from alcohol consumption. Despite these adverse effects, average lapsed time between realization that alcohol use led to personal problems and admission to intensive treatment was 10.28 years.

Tobacco use histories were characterized by greater variability. One respondent stated that he had smoked for only four years before quitting. All others though had smoked for at least 10 years. The average was 25; two reported essentially continuous smoking for 40 years or more. Most were heavy smokers. All but one estimated an average consumption of at least one pack per day. Most had made more than one serious attempt to quit smoking before entering treatment. Ah were smoking heavily at admission to treatment. Almost half (43%) were consuming two packs or more daily. Of the 14 participants, 10 reported hav- ing been informed of a major health problem that stemmed from their smoking.

Despite these substantial alcohol and tobacco use histories, summary statistics suggest that successful control of both drinking and smoking behaviors is at- tainable. Mean length of uninterrupted alcohol ab- stinence for this group was 6.5 years (minimum 6 years-2 months, maximum 7 years). The length of time since the last cigarette ranged from 4 to 7 years. The average was 5.5 years.

Impact of Smoking Cessation Efforts on the Maintenance of Sobriety

The impact of smoking cessation efforts on the main- tenance of sobriety was explored in several ways. De tailed post alcohol treatment substance use profiles were developed for each respondent. By recording the month and year that cessation attempts (alcohol and tobacco) began and, if appropriate, ended, it was possible to detect abstinence breaks that occurred subsequent to a smoking cessation attempt. In this sample, a resumption of drinking never followed a tobacco cessation attempt begun after discharge from intensive alcohol treatment.

Each respondent was further asked to agree or disagree, on the basis of their personal experience, with two statements: “Sometimes the stress of trying to avoid cigarettes has caused me to drink alcohol” and “When I first quit smoking, I really wanted to drink again.” All respondents strongly disagreed with the former while only one mildly agreed with the lat- ter. The one respondent who agreed had tried to quit smoking numerous times prior to alcohol treatment

and had found that he almost automatically resumed drinking when surrounded by smokers who were also drinking. In sum, direct and indirect assessments re- vealed no negative effects of smoking cessation ef- forts on alcohol abstinence.

Timing and Technique

The issue of ideal timing for a smoking cessation at- tempt was explored first by calculating the amount of time each of the 14 successful quitters had waited. Then, each was asked to recommend, on the basis of his experience, the amount of time a recovering alcoholic should wait after discharge from treatment before trying to quit smoking. The amount of time respondents had waited varid from less than one month to 8 years, 2 months (X = 36.21 months, SD = 31.83 months).

Recommendations to fellow alcoholics were more uniform. Two of the 14 recommended trying to quit smoking during treatment. Of the remaining 12 that supported waiting till after treatment, all but one thought that smoking cessation efforts could begin within a year or less. The discrepancy between per- sonal experience and advice to others may reflect re- cent changes in the general social acceptance of smoking.

To identify useful smoking cessation techniques for recovering alcoholics, the authors first developed a list of commonly used strategies: aversion therapy, counseling, education about the health consequences of smoking, going to a quit smoking clinic, increas- ing one’s exercise, relaxation training, and finding a buddy for moral support. Each participant was asked to affirm all of the strategies used in their most suc- cessful smoking cessation attempt. After the final item was read, another question asked about addi- tional techniques that were “especially helpful.” Table 1 ranks the various techniques from most to least frequently endorsed. Of particular note is the fact that adherence to AA principles, a spontaneously generated response, emerged as the most commonly used technique.

These findings suggest that a variety of cessation techniques can be used at varying post-discharge in- tervals by recovering alcoholics with severe substance abuse profiles. Three case histories further illustrate this diversity.

Case Example 1. Joe, a 33 year old, married physical therapist, started drinking on a regular basis at the age of 19. He drank without apparent problems for 10 years. After losing several friendships and getting injured in fights related to his alcohol consumption, he entered treatment. Treatment included counsel- ing, Antabuse, education about the health conse- quences of drinking, social skills training, nutrition

24 J.K. Bobo et al.

Table 1 Srnm cessation teebniquu usd by rerpondontr.

Item (N = 14)

Percent Reporting Use

Adhering to AA principles Finding a buddy for moral support Learning about the health consequences of smoking Increasing one’s exercise Participating in a quit smoking clinic Obtaining individual counseling Obtainlng training In relaxation methods Undergoing aversion therapy (rapid smoking)

76 50

;; 29

:t 14

and exercise, and participation in AA meetings. Dur- ing the 2 year 3 month interval between discharge from treatment and participation in the study, he maintained consistent abstinence.

He began smoking the same year he had started drinking and was soon consuming at least a pack of cigarettes a day. His serious attempts to quit smoking before alcohol treatment always floundered during drinking bouts. He felt that his drinking and smoking were strongly related and noted that whenever he quit drinking, he would start smoking “even more”. Mo- tivated by health concerns and social pressure, he tried to quit during his alcohol treatment program and on several occasions within the first six months after discharge. He attributed his initial failures largely to the number of smokers at AA meetings, noting that they tended to compromise his motiva- tion.

Not until his fourth attempt that began 8 months after completing treatment was he successful. At the time of the interview, Joe had not had a cigarette for 1 year and 7 months. He stated that his eventual suc- cess was due almost entirely to reliance on the AA motto of “one day at a time.”

Case Example 2. Pete, a 43 year old never married alcohol-drug treatment counselor, related a more se- vere history. He started drinking regularly as a teen- ager. Within five years, alcohol use was resulting in major problems including loss of friendships, loss of a job, a DWI conviction, other alcohol related ar- rests, malnutrition, and hepatitis. Nevertheless, he avoided intensive treatment for a number of years. Eventually, he entered a program much like Joe’s that incorporated a broad array of techniques. At the time of the interview, 4 years and 8 months had passed since his discharge; he had been continuously abstinent throughout that interval.

Pete was smoking at least l-2 cigarettes a day several years before he began regular drinking. He estimated that during most of his smoking career, he averaged a pack or more of cigarettes per day. Al- though he made several tobacco cessation attempts prior to alcohol treatment, his drinking bouts always

led to a relapse. Unlike Joe, he did not reattempt smoking cessation for almost a year and a half after alcohol treatment discharge. The first post treatment effort, however, was quite successful. With some pride, he noted that he had not had a cigarette for 3 years and 2 months.

Several factors may have contributed to the suc- cess of this effort. He was highly motivated by a friend who disapproved of his smoking, a desire to improve his health and self-esteem, and the deter- mination to successfully complete a marathon. He reinforced his cessation efforts in a number of ways, learning more about the health consequences of smoking, increasing his exercise, finding a buddy for moral support, and frequently reaffirming his desire to quit. Now, a confirmed nonsmoker, Pete feels most alcoholics should consider trying to quit smok- ing during intensive alcohol treatment.

Care Example 3. Tom, a 54 year old married ware- houseman, started drinking steadily as a young adult in the army. Consumption increased gradually over a 26 year period until a number of alcohol precipitated events-involvement in physical fights, loss of friend- ships and employment, plus several arrests- forced him into treatment. His treatment program excluded Antabuse but did use aversive therapy (electric shocks). Discharge from treatment was 7 years, 8 months prior to the interview. He had not had a drink during that interval.

Tom was smoking several cigarettes a day by the age of 13. By the time he entered alcohol treatment, he was averaging at least two packs daily. Despite development of a chronic cough and bronchitis, he did not attempt tobacco cessation for 6 years after completion of alcohol treatment.

Motivated by persistent encouragement from his spouse and fear of developing cancer, he eventually enrolled in a smoking cessation clinic that provided individual counseling and extensive health education. With counselor support and reliance on the “one day at a time” motto, he successfully quit smoking. Of note is the fact that he chose not to use aversive

Double Triumph 25

therapy. At the time of the interview, he had not had a cigarette for more than a year and an half.

DISCUSSION

These case histories and the data reported here sug- gest the feasibility of smoking cessation efforts for recovering alcoholics. Double triumphs are possible. Our findings may encourage alcohol treatment staff to more directly address client smoking. Education, modeling, and direct treatment can be used to assist client efforts.

Education is central. Clients need to be informed of the specific health risks smoking poses for al- coholics. They need to know that recovering alco- holics have used a wide variety of techniques to suc- cessfully quit and that the use of AA principles has proven particularly helpful for some. Ideal timing varies. Some may succeed within a few months of completing alcohol treatment. Others will need a year or more of lapsed time.

Recovering alcoholics on the treatment team pro- vide particularly potent substance use models. In 1981, Lewis concluded an essay addressed to physi- cians and nurses who smoke in the presence of their patients with this comment:

Smoking has been called a slow-motion death, and every professional might well consider whether his work need be so paradoxical. The professional strives against suicide, ad- diction, and carcinoma, while unthinkingly participating in slow suicide, undoubted addiction, and proven carcino- genesis. Worse, he encourages by example, for his patients learn to smoke as he does. Iatrogenic addiction, iatrogenic cancer. Are we all serious about Primum non nocere? (P. 503)

Alcohol treatment centers that allow staff and clients to smoke at all times send a strong and potentially harmful message. Counselors who openly discourage cessation efforts may severely compromise client motivation to quit.

Education and curtailment of smoking within the treatment center can be further coupled with direct support of client smoking cessation efforts. Support can range from occasional inquires about intentions to quit to scheduled discussions of different smoking cessation strategies. Treatment programs with post- discharge maintenance groups could collaborate with local smoking cessation clinics or extend their own alcoholism protocols to cigarette smoking.

CONCLUSION

Study participant experiences suggest that even recovering alcoholics with severe substance abuse his-

tories can successfully quit smoking without jeopar- dizing sobriety. The controversies that surround re- covering alcoholics and cigarette smoking, however, are far from resolved. Our conclusions are based on a small study that should be replicated. Treatment studies examining the long-term effectiveness of the various cessation techniques such as use of AA prin- ciples would also be informative.

REFERENCES

Ayers, J., Ruff, C.F., & Templer, D.I. (1976). Alcoholism, cigarette smoking, coffee drinking and extraversion. Joumu! of Studies on Alcohol, 37, 983-985.

Bobo, J.K., & Gilchrist, L.D. (1983). Urging the alcoholic client to quit smoking cigarettes. Addictive Behaviors, 8, 297-305.

Bobo, J.K., Gilchrist, L.D., Schilling, R.F.. Noach, B., & Schinke, S.P. (in press). Cigarette smoking cessation attempts by recovering alcoholics. Addictive Behaviors.

Dawley, H.H., Carrel. S., & Morrison, J. (1980). A comparison of hospitalized veterans’ attitudes over a four year period. Addictive Behaviors, 5, 241-245.

Dreher, K.F., & Fraser, J.G. (1967). Smoking habits of alcoholic out-patients. I. The International Journal of the Addictions, 2, 259-270.

Istvan, J., & Matarazzo, J.D. (1984). Tobacco, alcohol. and caffeine use: A review of their interrelationships. Psychologi- cal Bulletin, 98, 301-326.

Lewis, T.H. (1981). Staff smoking on the ward: Iatrogenic addic- tion, iatrogenic cancer. Hospital and Community &vchology, 32, 502-503.

Maletsky, B.M., & Klotter, J. (1974). Smoking and alcoholism. American Journal of Psychiatry. X31,445-447.

Marlatt, GA. (1985). Relapse prevention: Theoretical rationale and overview of the model. In G.A. Marlatt & J.R. Gordon (Eds.) Relapse prevention maintenance strategies in the treatment of atkiictive behaviors. New York: Guilford.

Miller, W.R., Hedrick, K-E., & Taylor, C.A. (1983). Addictive behaviors and life problems before and after behavioral treat- ment of problem drinkers. Addictive Behaviors, 8, 403-412.

Noble, E.P. (Ed.). (1978). Alcohol and health: Third special re- port to the U.S. Congm. Washington, DC: U.S. Depart- ment of Health, Education, and Welfare.

Office of Cancer Communications, Office of Cancer Control, Memorial Sloan-Kettering Cancer Center. Cancer Communi- cations, 1982. 6, 2.

Remington, P.L., Forman, M.R., Gentry, E.M., Marks, J.S., Hogelin, G.C.. & Trowbridge, F.L. (1985) Current smoking trends in the United States: the 1981-1983 behavioral risk factor surveys. Journal of the American Medical Aswciation, 253. 2975-2978.

Qhilling, R.F., Gilchrist. L.E., & Schinke, S.P. (1985). Smoking in the workplace: review of critical issues. Public Health Re- ports, 100.473-479.

U.S. Department of Health and Human Services. (1982). The health consequent of smoking: &uxr: A report of the Surgeon General. Washington, DC U.S. Government Print- ing Office.

United States Public Health Service, Department of Health, Edu- cation, and Welfare (1979). Smoking and heaithz A Report of the Surgeon General. W’ashington DC: U.S. Government Printing Office.