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

1. 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.

2. 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.

3. 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.

4. 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.

5. McIlvain HE, Bobo JK, Leed-Kelly A, Sitorius MA. Practical steps to smoking cessation for recovering alcoholics. Am Fam Physician (in press).

6. 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.

7. Institute of Medicine. Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press, 1990.

8. CDC. Smoking cessation during previous year among adults -- United States, 1990 and 1991. MMWR 1993;42:504-7.

9. 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.

10. 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. 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.
==========================================================================================================================================================================================================================================

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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