RESEARCH
Relationship between alcohol and tobacco dependencies among alcohol dependents who smoke
R Sreevani, Jairakini Aruna1, Gajendra2
MSc in Psychiatric Nursing, PhD in Nursing, Prof and HOD, Dept of Psychiatric Nursing, Dharwad Institute of Mental Health and Neuro Sciences, Dharwad, Karnataka, India
1MSc in Psychiatric Nursing, Associate Professor, Dept of Psychiatric Nursing, Sri Devaraj Urs College of Nursing, Tamaka, Kolar, Karnataka, India
2II year MSc Nursing Student, Sri Devaraj Urs College of Nursing, Tamaka, Kolar, Karnataka, India
Abstract
Background: Tobacco and alcohol are the most widely used psychoactive substances. Most of the studies show close relationship between the use of alcohol and smoking. In general population, smokers are more likely to drink than non-smokers.
Materials and methods: The cross-sectional study was conducted with 100 alcohol dependents who were taking treatment at two selected de-addiction centres. This study utilised the following measures: (a) socio-demographic data sheet, (b) alcohol and smoking history data sheet, (c) alcohol dependence scale, and (d) Fagerstrom test for nicotine dependence.
Results: There was a significant correlation between age of onset of smoking with age of onset of alcohol intake, years of alcohol dependence with years of smoking dependence, mean days of drinking with mean days of smoking, and average consumption of alcohol per day with number of cigarettes smoked per day.
Conclusion: Alcohol use and smoking are correlated; the link between alcohol and tobacco has important implications for those in the field of alcohol treatment.
Sreevani R, Aruna J, Gajendra. Relationship between alcohol and tobacco dependencies among alcohol dependents who smoke. Dysphrenia. 2014;5:114-8.
Keywords: Nicotine. Age of Onset. Risk Factors. Treatment Outcome.
Correspondence: sreevani.phd@gmail.com, ambati.giri@gmail.com
Received on 23 March 2014. Accepted on 3 May 2014.
Introduction
Alcohol and tobacco are the substances often used together. Studies have found that people who smoke are much more likely to drink and vice-versa.[1] Extensive research supports the popular observation that “smokers drink and drinkers smoke”.[2-4] Dependence on alcohol and tobacco is correlated. People who are dependent on alcohol are three times more likely than those in the general population to be smokers, and people who are dependent on tobacco are four times more likely than the general population to be dependent on alcohol.[5] Interactions between tobacco smoking and alcohol drinking have been shown by several studies.[2,4,6-8] Chronic smoking may contribute to a tolerance of the effects of alcohol consumption, and may increase alcohol metabolism.[9]
Health consequences of combined use, biological mechanisms and genetic vulnerabilities to co-dependence are barriers to the treatment of tobacco dependence in patients with alcohol and other drug use disorders.[1] More than half of patients in treatment for alcohol dependence die from tobacco-related illnesses.[10] Yet, tobacco addiction often is not addressed in recovering alcohol dependents. One of the major barriers to treating tobacco dependence in patients with a co-occurring alcohol use disorder is the notion that it is too difficult to quit both alcohol and tobacco, and that attempts to quit tobacco might adversely affect the patient’s recovery from alcohol use.[11,12]
Despite the high prevalence of tobacco use among people with substance use disorders, tobacco dependence is often overlooked in addiction treatment programmes. Treatment facilities often concentrate on the “primary” addiction to alcohol and treat tobacco use as a more benign addiction. Many treatment facilities do not screen for or treat tobacco dependence.[13] Several studies and a meta-analytic review have concluded that patients who receive tobacco dependence treatment during addiction treatment have better overall substance abuse treatment outcomes compared with those who do not.[13]
To control the harmful action of alcohol and tobacco use, and to reduce its impact on the individual and society, it is important to treat for dependence on both substances. The link between alcohol and tobacco has important implications for those in the alcohol treatment field. Despite the extensive literature investigating relationship between alcohol dependence and tobacco smoking, a detailed examination is needed for the interaction between alcohol and smoking onset, years of dependence of alcohol and smoking, amount of consumption of alcohol and smoking among treatment seeking alcohol dependents.
The main aim of the present study is to find out the relationship between alcohol and tobacco use among alcohol dependents who smoke. The objectives of the present study are to find out the correlation between alcohol and smoking age of onset, years of dependence between alcohol and smoking, mean days of drinking with mean days of smoking, average consumption of alcohol per day with number of cigarettes smoked per day.
Materials and methods
The sample comprised of 100 alcohol dependents, who were recruited from two de-addiction centres of Kolar District, Karnataka, India by using convenience sampling technique. Inclusion criteria were: (a) diagnosed with alcohol dependent syndrome according to the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10);[14] (b) aged between 20 to 60 years; (c) able to understand regional language or English. Subjects with severe withdrawal symptoms, with severe psychotic symptoms were excluded.
Assessment
The study obtained permission from the concerned authorities of de-addiction centres. Data were collected on the basis of a single cross-sectional interview of the subjects who fulfilled the inclusion and exclusion criteria, and provided written informed consent. Subjects were administered the socio-demographic proforma, alcohol and smoking history proforma, alcohol dependence scale (ADS),[15] and Fagerstrom test for nicotine dependence (FTND).[16,17]
1. Socio-demographic proforma: It includes questions on their age, marital status, occupation, religion, type of family, area of residence, and mean monthly income.
2. Alcohol and smoking history proforma: It includes questions on age of onset of alcohol and smoking use, number of years of dependence, family history of alcohol use and smoking, number of days of drinking per month, number of days of smoking per month, average consumption of alcohol and number of cigarettes smoked per day.
3. ADS: It was developed by Skinner and Allen in 1982. It provides a quantitative measure of the severity of alcohol dependence. It consists of 25 items rated on zero to three scale, covers alcohol withdrawal symptoms, impaired control over drinking, awareness of a compulsion to drink, increased tolerance to alcohol, and salience of drink-seeking behaviour.
Scoring: Dichotomous items are scored zero, one; three-choice items are scored zero, one, two; and four-choice items are scored zero, one, two, three.
Score range: Zero to 47; higher the value, the greater the dependence.
The ADS is widely used as a research and clinical tool, and studies have found the instrument to be reliable and valid. The ADS has been found to have excellent predictive value with respect to a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis. Moreover, the ADS yields a measure of the severity of dependence that is important for treatment planning, especially with respect to the intensity of treatment.[15]
4. FTND: It was developed by Heatherton, Kozlowski, Frecker, and Fagerstrom in 1991. This six item test was developed with the aim to diagnose the degree of dependence among smokers coming to a clinic seeking for help with stopping smoking rated on zero to three scale. The test can be filled out either by the therapist/researcher or the smoker. It contains items that evaluate the quantity of cigarette consumption, the compulsion to use, and dependence. It has been found to correlate with need to smoke in the night, ability to stop smoking, withdrawal symptoms including physiological variables. Total scores should range from zero to 11, with seven or greater suggesting physical dependence on nicotine.[16,17]
Statistical analysis
The Statistical Package for the Social Sciences (SPSS) software (version 15) was used to analyse the data. Descriptive statistics were used for all variables. Pearson’s analysis was used for the correlation between alcohol and tobacco use scores.
Results
The socio-demographic characteristics of the study sample are presented in table 1. Mean age of the sample was 33.33±8.93 years. Fifty five per cent of the samples were married; majority (91%) belonged to Hindu religion. The largest proportion (74%) of the participants belonged to nuclear family. More than half of the subjects (53%) were residing in urban area. Forty per cent of the sample was private employees. Mean monthly income of the sample was Rs. 13,585±9,105.
Subject’s alcohol history was presented in table 2. Mean age of onset of alcohol intake was 23.56±6.68 years, mean years of dependence on alcohol was 9.66±6.72, mean attempts of abstinence were 1.66±2.49, mean days of drinking per month was 24.94±5.70, mean average consumption of alcohol per day was 284.30±181.30 ml. Nearly half of the sample (44%) had family history of alcohol intake, and among them 72.72% were fathers. Fifty nine per cent of the alcohol dependents having smoking habit, remaining (41%) alcohol dependents having chewing tobacco habit. Mean alcohol dependence score was 31.93 (8.03).
Smoking history of the subjects is presented in table 3. Mean age of onset of smoking is 20.44±4.73 years, mean number of years of dependence to smoking was 10.73±5.77. Mean number of cigarettes smoked per day was 11.98±6.84. Sixty eight per cent of the sample had family history of smoking, among them 49.15% were fathers. Mean smoking dependence score was 5.34±2.09.
|
Table 1: Description of socio-demographic characteristics of subjects (N=100) |
||
|
Socio-demographic characteristics |
Frequency |
|
|
Mean age (SD) |
33.33 (8.93) |
|
|
Education |
Illiterate Up to tenth standard Tenth standard to pre-university Degree Degree and above |
7 42 26 14 11 |
|
Marital status |
Single Married |
45 55 |
|
Religion |
Hindu Muslim Christian |
91 7 2 |
|
Type of family |
Nuclear Joint and Extended |
74 26 |
|
Area of residence |
Urban Rural |
53 47 |
|
Occupation |
Agriculture Govt employee Private employee Own business Unemployed |
33 9 42 10 6 |
|
Mean monthly income (SD) |
Rs. 13,585 (Rs.9,105) |
|
|
SD=standard deviation |
||
Table 4 shows positive correlation between the severity of cigarette smoked and severity of alcohol intake; as the alcohol dependence score is increasing, smoking dependence score also increasing.
Pearson’s correlation was calculated to examine the relationship between age of onset of alcohol intake with age of onset of cigarette smoking; the scores were positively correlated (r=0.47) (table 5), indicating as alcohol intake started at younger age, cigarette smoking also started in younger age.
Table 6 indicates that very large correlation between years of dependence on alcohol with years of dependence on smoking; as years of dependence increased with alcohol, years of smoking dependence also increased.
The table 7 findings show that mean days of drinking alcohol is positively correlated with mean days of smoking; as days of drinking of alcohol is increased, days of smoking also increased. Regular drinkers are regular smokers.
Correlation results show that average consumption of alcohol per day is positively correlated with number of cigarettes smoked per day (table 8); indicating that alcohol
|
Table 2: Description of alcohol history among subjects (N=100) |
||
|
Alcohol history |
Frequency/Mean (SD) |
|
|
Mean age of onset of alcohol intake |
23.56 (6.68) |
|
|
Mean number of years of dependence on alcohol |
9.66 (6.72) |
|
|
Mean number of attempts of abstinence |
1.66 (2.49) |
|
|
Mean number of days of drinking per month |
24.94 (5.70) |
|
|
Mean average consumptions of alcohol per day |
284.30 (181.30) |
|
|
Family history of alcohol intake |
Yes No |
44 56 |
|
History of alcohol intake |
Father Brother Others |
32 (72.72) 8 (18.80) 4 (9.09) |
|
Other substance abuse |
Smoking Chewing tobacco Other |
59 41 0 |
|
Mean alcohol dependence score (maximum score 47) |
31.93 (8.03) |
|
|
SD=standard deviation |
||
|
Table 3: Description of smoking history among alcohol dependents (N=100) |
||
|
Smoking history |
Frequency/Mean (SD) |
|
|
Mean age of onset of cigarette smoking |
20.44 (4.73) |
|
|
Mean number of years of dependence to smoking |
10.73 (5.77) |
|
|
Mean number of days of smoking per month |
28.88 (4.17) |
|
|
Mean number of cigarettes smoked per day |
11.98 (6.84) |
|
|
Family history of smoking |
Yes No |
40 (68%) 19 (32%) |
|
History of smoking |
Father Brother Others |
29 (49.15) 8 (13.55) 3 (5.08) |
|
Mean smoking dependence score (maximum score ten) |
5.34 (2.09) |
|
|
Table 4: Correlation between alcohol dependence score and smoking dependence score among alcohol dependents |
||
|
Variables |
Smoking dependence score |
p value |
|
Alcohol dependence score |
0.52 |
0.001 |
|
Table 5: Correlation between age of onset of alcohol intake and age of onset of smoking |
||
|
Variables |
Age of onset of cigarette smoking |
p value |
|
Age of onset of alcohol intake |
0.47 |
0.001 |
|
Table 6: Correlation between years of alcohol dependence and years of smoking dependence |
||
|
Variables |
Years of dependence on smoking |
p value |
|
Years of dependence on alcohol |
0.51 |
0.001 |
|
Table 7: Correlation between mean days of drinking alcohol and mean days of smoking |
||
|
Variables |
Mean days of smoking |
p value |
|
Mean days of drinking alcohol |
0.40 |
0.001 |
|
Table 8: Correlation between average consumption of alcohol per day and number of cigarettes smoked per day |
||
|
Variables |
Number of cigarettes smoking per day |
p value |
|
Average consumption of alcohol per day |
0.26 |
0.04 |
consumption per day increased with number of cigarettes smoked per day.
Discussion
A positive correlation was detected between the severity of cigarette smoking and severity of alcohol intake, age of onset of alcohol intake with age of onset of smoking, years of alcohol dependence and years of smoking dependence; mean days of drinking was positively correlated with mean days of smoking, average consumption of alcohol per day was positively correlated withnumber of cigarettes smoked per day. In light of the multiple levels of correlation of variables, each tends to be a risk factor for the other.
The present study results were consistent with previous studies
A study was conducted on men and women to find out co-occurent use of cigarettes and alcohol; results showed that there is more alcohol consumption among current as well as former smokers than among non-smokers.[18] In health maintenance study, there were more alcohol-dependent individuals among smokers than among non-smokers.[19] A study was conducted on alcohol dependents who used both tobacco and alcohol in the preceding week. Results showed that the prevalence of smoking among alcohol depen-dents was 88%. The amount of tobacco smoked was correlated to the amount of alcohol consumed and severity of alcohol depen-dence.[20] A national survey study assessed relationship between tobacco use and substance use disorders among community living sample; results showed that current daily smokers had a higher rate of alcohol dependence than never, former or occasional smokers.[21]
A trend toward lower ages of alcohol use is noted and Bhagabati et al.[22] studied the pattern of alcohol consumption in underage population in an Indian city. One hundred and fifty one (22.2%) subjects out of total 680 participants from six randomly selected schools have ever had alcoholic beverages like beer, wine or liquour.[22]
Limitations
Study was done on cross-sectinal data from a small sample size from a deaddiction center. Information was gathered as self-statements and no biochemical verification was done, there are available biochemical measurements [23]. The FTND had been assessed in current smokers only.
Recommendations
The relationship between drinking and smoking should be targeted at both. Studies should be done with bigger and heterogenous samples. There is a crucial need to consider smoking when treating alcohol.
Conclusion
Prevalence of tobacco use is high among alcohol users. Addition of tobacco dependence treatment during addiction treatment will have better overall substance abuse treatment outcomes.
Source of support: Nil. Declaration of interest: None.
References
1. Bobo JK, Husten C. Sociocultural influences on smoking and drinking. Alcohol Res Health. 2000;24:225-32.
2. Hughes JR. Clinical implications of the association between smoking and alcoholism. In: Fertig JB, Allen JP, editors. Alcohol and tobacco: from basic science to clinical practice. NIAAA Research Monograph No. 30. NIH Pub. No. 95-3931. Washington, DC: Supt. Of Docs., US Govt. Print. Off.; 1995. p. 171-85.
3. Patten CA, Martin JE, Calfas KJ, Lento J, Wolter TD. Behavioral treatment for smokers with a history of alcoholism: predictors of successful outcome. J Consult Clin Psychol. 2001;69:796-801.
4. Balogh SA, Owens JC, Butt CM, Wehner JM, Collins AC. Animal models as a tool for studying mechanisms of co-abuse of alcohol and tobacco. Alcohol Clin Exp Res. 2002;26:1911-4.
5. Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA. Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry. 2004;61:1107-15.
6. Batel P, Pessione F, Maître C, Rueff B. Relationship between alcohol and tobacco dependencies among alcoholics who smoke. Addiction. 1995;90:977-80.
7. Gulliver SB, Kamholz BW, Helstrom AW. Smoking cessation and alcohol abstinence: what do the data tell us? Alcohol Res Health. 2006;29:208-12.
8. Zacny JP. Behavioral aspects of alcohol–tobacco interactions. In: Galanter M, editor. Recent developments in alcoholism. New York: Plenum Press; 2000. p. 205-19.
9. Henningfield JE, Heishman SJ. The addictive role of nicotine in tobacco use. Psychopharmacology (Berl). 1995;117:11-3.
10. Hurt RD, Offord KP, Croghan IT, Gomez-Dahl L, Kottke TE, Morse RM, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA. 1996;275:1097-103.
11. Walsh RA, Bowman JA, Tzelepis F, Lecathelinais C. Smoking cessation interventions in Australian drug treatment agencies: a national survey of attitudes and practices. Drug Alcohol Rev. 2005;24:235-44.
12. Zullino DF, Besson J, Favrat B, Krenz S, Zimmermann G, Schnyder C, et al. Acceptance of an intended smoking ban in an alcohol dependence clinic. Eur Psychiatry. 2003;18:255-7.
13. Ziedonis DM, Guydish J, Williams J, Steinberg M, Foulds J. Barriers and solutions to addressing tobacco dependence in addiction treatment programs. Alcohol Res Health. 2006;29:228-35.
14. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines [Internet]. Geneva: World Health Organization; 1992 [cited 2014 May 4]. Available from: http://www.who.int/classifications/icd/en/bluebook.pdf
15. Skinner HA, Allen BA. Alcohol dependence syndrome: measurement and validation. J Abnorm Psychol. 1982;91:199-209.
16. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991;86:1119-27.
17. Fagerström K. Determinants of tobacco use and renaming the FTND to the Fagerstrom Test for Cigarette Dependence. Nicotine Tob Res. 2012;14:75-8.
18. Carmody TP, Brischetto CS, Matarazzo JD, O’Donnell RP, Connor WE. Co-occurrent use of cigarettes, alcohol, and coffee in healthy, community-living men and women. Health Psychol. 1985;4:323-35.
19. Breslau N. Psychiatric comorbidity of smoking and nicotine dependence. Behav Genet. 1995;25:95-101.
20. John U, Meyer C, Rumpf HJ, Hapke U. Probabilities of alcohol high-risk drinking, abuse or dependence estimated on grounds of tobacco smoking and nicotine dependence. Addiction. 2003;98:805-14.
21. Degenhardt L, Hall W. The relationship between tobacco use, substance-use disorders and mental health: results from the National Survey of Mental Health and Well-being. Nicotine Tob Res. 2001;3:225-34.
22. Bhagabati D, Das B, Das S. Pattern of alcohol consumption in underage population in an Indian city. Dysphrenia. 2013;4:36-41.
23. Chisty SJS, Das D. Biomarkers in the treatment of alcohol use disorders. Dysphrenia. 2012;3:21-31.
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