Concurrent treatment for alcohol and tobacco dependence: are patients ready to quit both?

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Abstract

The prevalence of smoking among alcohol abusers is high, yet little is known about this dual-dependency. This study examines mechanisms involved in changing both alcohol and tobacco use concurrently using the transtheoretical model (TTM) measures of change. Alcohol and tobacco dependent outpatients (N=115) entering a dual-substance dependence program were compared on baseline measures of motivation, self-initiated change activities, and self-efficacy associated with each substance use behavior. Differences on these measures were expected for drinking versus smoking. Motivation to change each behavior was also examined as a potential predictor of retention in treatment. Results indicated that patients reported higher self-efficacy to abstain and lower temptation to use alcohol relative to cigarettes. Change activities were also initiated at higher levels for drinking compared with smoking. An interaction between drinking and smoking motivation for change was found in the prediction of treatment retention; those with higher motivation for changing their alcohol use and lower motivation to quit smoking remained longer in treatment, while those who were higher in motivation for changing both behaviors dropped out the earliest. Overall, participants in this dual-dependence program were more confident and active in changing their alcohol use. Initiating cessation of both behaviors equally and simultaneously may prove difficult for this population. This study initiates an understanding of the mechanisms involved in changing alcohol–tobacco dependence and may provide guidance for developing dual cessation interventions.

Introduction

The prevalence of smoking among alcohol abusers is considerably higher than rates in the general population, 80–90 and 25%, respectively (Batel et al., 1995, DiFranza and Guerrera, 1990, Hurt et al., 1996). Recent research has documented the strong association between alcohol and tobacco smoking. For example, smoking rate was positively correlated with amount of alcohol consumed and severity of alcohol dependence in alcohol treatment outpatients (Batel et al., 1995). Also, nicotine deprivation has been associated with increased urges to drink, cognitions regarding alcohol, and alcohol consumption in alcohol-abusing smokers (Palfai et al., 2000). It has also been found that individuals with a more severe alcohol dependency tend to be more nicotine dependent than less severe or non-drinkers, and their odds of smoking cessation are reduced (Daeppen et al., 2000, Dawson, 2000, Hurt et al., 1996).

Despite the high concurrence of alcohol and tobacco dependence, alcohol treatment programs have been reluctant to promote smoking cessation, presumably because of lack of interest among patients or potential negative effects on alcohol treatment outcomes (Bobo and Gilchrist, 1983, Burling et al., 1997, Sees and Clark, 1993). Recent research has suggested otherwise, however, Ellingstad et al. (1999) reported that 77% of alcohol treatment-seeking individuals who were also smokers reported a willingness to consider stopping smoking during or after alcohol treatment. Further, initiating smoking cessation during or subsequent to alcohol treatment has not significantly jeopardized abstinence (Bobo et al., 1998, Burling et al., 2001, Burling et al., 1991, Hurt et al., 1994).

Smoking cessation interventions with current or past alcohol dependent individuals have met with limited success, however. Reductions in smoking tend to be small, short-term, and lower than those typically found with non-substance abusing populations (Bobo et al., 1998, Burling et al., 2001, Burling et al., 1991, Campbell et al., 1995). Therefore, although alcohol and drug abusers may be interested and willing to participate in smoking cessation treatment, consistently positive smoking outcomes have yet to be achieved in these populations.

Understanding and examining the process of change for both alcohol and smoking cessation has been a central focus of the Transtheoretical Model (TTM) (DiClemente and Prochaska, 1998, Prochaska and DiClemente, 1984). Three interrelated constructs, stages of change, processes of change (POC), and self-efficacy have been used to describe and predict smoking and drinking outcomes (Carbonari and DiClemente, 2000, Perz et al., 1996, Stotts et al., 2000, Stotts et al., 2001). For example, stage or readiness for change was the strongest predictor of drinking behavior in the 1-year follow-up of a large alcohol treatment matching study (Project MATCH Research Group, 1997a). Stage of change also has been found to be a strong predictor of postpartum relapse to smoking (Stotts et al., 2000). Similarly, higher levels of process or change activity have been associated with increased motivation for change and positive smoking outcomes (DiClemente et al., 1991). The self-efficacy component of the TTM measures both confidence to resist drinking and temptation to drink, and has been found to be a robust predictor of both smoking and drinking outcomes (DiClemente et al., 1991, Project MATCH Research Group, 1997b).

Numerous studies have evaluated the TTM variables related to changing smoking and drinking behaviors independently. However, none has examined these variables in the context of changing both concurrently. Based on past findings, it is expected that success in changing both behaviors will, in part, depend on relative levels of readiness, self-efficacy, and self-initiated change activity associated with each behavior. Understanding how these variables interact in alcohol–tobacco dependent patients may provide important information toward developing dual cessation interventions.

This study compared baseline variables related to quitting drinking and smoking in outpatients entering a dual-substance dependence treatment program. It was hypothesized that the TTM variables of motivation to change, self-efficacy, temptation, and POC would be different for drinking versus smoking. Due to the traditional emphasis on alcohol treatment relative to smoking cessation, we expected that dual-dependent patients would be more ready to change their drinking behavior. In addition, although the treatment study for which these data were collected is ongoing, preliminary retention data are presented as a function of baseline motivation to change. It was hypothesized that higher motivation to change both alcohol and nicotine use would be associated with longer retention in treatment.

Section snippets

Research participants

Participants (N=115) were consecutive admissions to the Treatment Research Clinic (TRC) in Houston, TX for a program targeting both alcohol and nicotine dependence concurrently. The TRC is a university medical center-based research facility and has been described elsewhere by Elk et al. (1993). To be included in this study, participants had to be English-speaking adults between the ages of 18 and 60, able to participate in 12 weeks of outpatient treatment, free of serious legal and medical

Sample characteristics

Participants were an average (±S.D.) age of 41.8 (9.4) and most were male (70%). Eighty-one percent were Caucasian, 10.4 and 8% were Africian–American and Hispanic, respectively. The average number of years of education was 14.2 (2.5) and 63.6% were employed. In the past 90 days, participants consumed alcohol on an average of 74 (20.1) days, with the mean number of standard drinks per drinking day being 9.1 (7.3). The average score on the ADS was 17.7 (7.9). With regard to nicotine,

Discussion

Although the alcohol–tobacco dependent patients in this study expressed an interest in quitting both substances, results indicated clear differences in their attitudes, beliefs, and behaviors associated with each. These dual-dependent patients reported higher self-efficacy to abstain and lower temptation to use alcohol relative to cigarettes. In addition, at baseline they had initiated change processes at higher levels for their alcohol problem compared with smoking. In addition, an interesting

Acknowledgements

This research was supported by a National Institute of Alcoholism and Alcohol Abuse grant (#AA11216-03). We would also like to acknowledge Shelly Sayre and Patti Hokanson for their contributions to the data collection/management aspects of this paper.

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