PREVENTION AND TREATMENT

IN CLINICAL HEALTH

Abstract Individuals who use alcohol have been found to be more likely to smoke cigarettes (Substance Abuse and Mental Health Services Administration, 2011). For example when college students drink they are more likely to smoke cigarettes at a higher rate, and when they smoke, they are more likely to drink at higher rates (Witkiewitz, et al., 2011). However, few studies have examined the relationship between change in drinking behavior over time and smoking cessation-related outcomes. The aim of the present study was to examine whether reductions in drinking were associated with a concomitant reduction in smoking status in a sample of light and intermittent smokers. The present sample is a subgroup of participants (n= 213, 56.3% female, 85% Hispanic; Mage = 38, SD = 14.7) who completed baseline and 3 month follow-up measures as part of larger intervention studies that examined the efficacy of a brief smoking intervention in light and intermittent smokers. Participants were recruited from local health care clinics and a university on the U.S./México border and completed measures of demographics, tobacco use and history, and the Daily Drinking Questionnaire (DDQ; Collins, Park, & Marlatt, 1985) at baseline and 3 month follow-up. Smoking status was measured on a 7 point scale (1= greater than 10 cigarettes a day to 7= quit smoking), and drinking in the past month was measured on a 7 point scale (1= did not drink to 7= drank once a day or more). Descriptive analyses indicated that smoking and drinking rates declined at follow-up regardless of intervention condition. Participants who reported smoking less than once a week increased from 12.1% at baseline to 24.1% at the 3 month follow-up. Regarding drinking behavior, reports of not drinking at all in the past 30 days increased from 32.2% at baseline to 38.1% at the 3 month follow-up. A hierarchical linear regression analysis was conducted to assess the relationship between smoking status at follow-up (dependent measure) and change in alcohol use status (baseline subtracted from 3 month follow-up). In step 1, relevant covariates were entered in the following order: smoking status at baseline, intervention condition, age, and gender, which collectively accounted for 24.8% of the variance in smoking status at follow-up. In step 2, change in drinking score was included in the analysis and was a significant predictor (B= -.24, p =.02) of smoking status at follow-up and uniquely accounted for 1.9% of the variance. Results indicate that reductions in drinking are associated with lower smoking rates. Previous research indicates that light smokers in particular are more likely to smoke while drinking (Jackson, Colby, & Sher, 2010), and in a Hispanic sample, smokers are more likely to report greater alcohol use than non-smokers (Cooper, Rodriguez, Charter, & Blow, 2011). Implications of these findings are that efforts aimed to reduce smoking may be paired with components aimed to reduce alcohol drinking in order to enhance the effectiveness of cessation interventions prioritizing light and intermittent smokers.

Aims and Hypotheses

The purpose of this study was to asses the relationships between smoking and drinking over time. It was predicted that decreased smoking rates would be associated with decreased drinking status at a three month follow-up.

Introduction

Tobacco is the leading cause of preventable death in the United States (Centers for Disease Control and Prevention [CDC], 2011). Over 50% of Americans report being alcohol users, and over 11% have driven under the influence of alcohol in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). Additionally, individuals who use alcohol have been found to be more likely to smoke cigarettes (SAMHSA, 2011). Among college students, though rates of cigarette smoking have traditionally been lower compared to their non college peers (7.0% vs. 21% in 2011), alcohol use rates have been higher (Johnston, O’Malley, Bachman, & Schulenberg, 2012). Notably, there is a reciprocal relationship between smoking and drinking, such that the more individuals drink the more likely they are to smoke cigarettes and vice-versa (Witkiewitz, 2011). Moreover, past research has demonstrated that light smokers in particular are more likely to smoke cigarettes while drinking (Jackson, Colby, & Sher, 2010). One study that examined alcohol and tobacco use treatment seeking adults found that increased confidence to not smoke was significantly associated with not drinking (Holt, Litt, & Cooney, 2012). Furthermore, individuals who have no intention of quitting smoking are more likely to engage in binge drinking (Ling, Neilands, & Glantz, 2009). Few studies have examined whether changes in drinking behavior are associated with concomitant changes in smoking behavior over time. As such, the current study investigated whether reductions in smoking were associated with reductions in drinking among a sample of light and intermittent smokers recruited from a local health clinic and a university on the U.S. / México border.

Methods Procedure and Participants Three hundred and seventy six community light and intermittent smokers participated in a study that examined the efficacy of a brief smoking intervention in light and intermittent smokers. The current data was collected throughout two different sequential grant cycles. Participants were recruited from community health clinics and at a local university. Participants were randomized to participate in either an immediate treatment condition or a delayed (3 month follow-up) treatment condition. Participants completed the informed consent process and a self-report survey both at baseline and at a 3month follow-up. The current study examined a subsample of 213 participants who completed both baseline and 3 month follow-up assessment. See Table 1 for descriptive statistics. Measures •A typical sociodemographic questionnaire that included ethnicity, age, and gender was collected and has been used in previous studies (Cooper et. al., 2011). • A tobacco use history survey that measured smoking status on a 7 point scale ranging from 1 (greater than 10 cigarettes a day) to 7 (smoked in past/quit) (see Figure 1). ). •Drinking Quantity/Frequency Index (Cahallan’s Q/F Index) which is an adaptation from The Drinking Quantity/Frequency (DDQ; Collins, Parks, & Marlatt, 1985) assessed the number of drinks during the past month on a 7 point Likert scale ranging from 1 (did not drink at all) to 7 (drank once a day or more) (see Figure 2). The internal reliability of this scale has ranged between .73 and .78 (Geisner, Larimer, & Neighbors, 2004). Approach to Analyses A 2-step hierarchical linear regression was performed using smoking status at the 3 month follow-up as the dependent variable. In step 1, covariates were entered in the following order: baseline smoking status, intervention condition, age, and gender. In step 2 (Table 2), change in drinking status (baseline subtracted from 3 month follow-up) was also included in the model.

Table 1: Descriptive Characteristics

% Mean SD

Male

Female

43.7

56.3

Age 37.74 14.65

Ethnicity

Hispanic

Non-Hispanic White

African American

Asian American

Other

84.7

6.1

1.4

.5

7

Results

The overall regression model was significant, as well as each of the steps (step 1 R2=.248, p<.001; step 2 R2=.268, p<.001). In step 1, only smoking status at baseline was significantly related (β= -.478, p<.001) with smoking status at follow-up. In step 2, after controlling for the covariates, change in drinking status (β= -.139, p=.021) was significantly associated with smoking status at the 3 month follow-up (see Table 2).

Discussion Consistent with past research (Rodriguez-Esquivel, Cooper, Blow, & Resor, 2009), and with the study hypothesis, a significant relationship between smoking and drinking was found such that lower smoking status was associated with decreased drinking status. Additionally, overall participants reduced both in smoking and drinking levels regardless of intervention condition (immediate vs. delay intervention) at 3 month follow-up. It may be that those individuals who decide to quit smoking, may have a general increase in healthy behavior. It could also be that smokers have an easier time reducing and/or quitting smoking when they are able to reduce and/or stop drinking, which for many smokers could be a strong trigger to smoke. Given the results of this study, smoking cessation programs may benefit from including intervention components that also aim to reduce alcohol use. For example, the inclusion of trigger management components specific to alcohol and cigarettes may be particularly effective in light and intermittent smokers since their smoking behavior tends to be strongly affected by environmental and psychosocial factors. Limitations of this study include the use of self-report measures, a short follow-up period (3 months), and the potential lack of generalizability to other ethnocultural and higher smoking status groups. Future studies should examine if this reciprocal relationship is observed in other groups, over longer periods of time. Further, focused paired intervention efforts should assess concomitant changes over time.

References Centers for Disease Control and Prevention. (2011). Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years ---

United States, 2005--2010. Morbidity and Mortality Weekly Report, 60, 1207-1212. Collins, R. L., Parks, G. A., & Marlatt, G. A. (1985). Social determinants of alcohol consumption: the effects of social interaction

and model status on the self-administration of alcohol. Journal of Consulting and Clinical Psychology, 53, 189-200. Cooper, T. V., Rodríguez de Ybarra, D., Charter, J. E., & Blow, J. (2011). Characteristics associated with smoking in a Hispanic

college sample. Addictive Behaviors, 36, 1329-1332. doi: 10.1016/j.addbeh.2011.07.021 Geisner, I. M., Larimer, M. E., & Neighbors, C. (2004). The relationship among alcohol use, related problems, and symptoms of

psychological distress: Gender as a moderator in a college sample. Addictive Behaviors, 29, 843-848. Holt, L. J., Litt, M. D., & Cooney, N. L. (2012). Prospective analysis of early lapse to drinking and smoking among individuals in

concurrent alcohol and tobacco treatment. Psychology Of Addictive Behaviors, 26(3), 561-572. doi:10.1037/a0026039 Jackson, K. M., Colby, S. M., & Sher, K. J. (2010). Daily patterns of conjoint smoking and drinking in college student smokers.

Psychology Of Addictive Behaviors, 24(3), 424-435. doi:10.1037/a0019793 Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future national survey results on drug

use, 1975–2011: Volume II, College students and adults ages 19– 50. Ann Arbor: Institute for Social Research, The University of Michigan.

Ling, P. M., Neilands, T. B., & Glantz, S. A. (2009). Young adult smoking behavior: A national survey. American Journal Of Preventive Medicine, 36(5), 389-394. doi:10.1016/j.amepre.2009.01.028

Rodríguez-Esquivel, D., Cooper, T., Blow, J., & Resor, M. (2009). Characteristics associated with smoking in a Hispanic sample. Addictive Behaviors, 34(6-7), 593-598. doi:10.1016/j.addbeh.2009.03.030.

Substance Abuse and Mental Health Services Administration. [SAMHSA] (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.

Witkiewitz, K., Desai, S. A., Steckler, G., Jackson, K. M., Bowen, S., Leigh, B. C., & Larimer, M. E. (2012). Concurrent drinking and smoking among college students: An event-level analysis. Psychology Of Addictive Behaviors, 26(3), 649-654. doi:10.1037/a0025363

Acknowledgements

This study was funded the Paso Del Norte Health Foundation Grant Nos. 26-8113-29 and 26-8113-48.

The Relationship between Changes in Drinking Over Time and Smoking Status among Light and Intermittent

Smokers Joseph E. Charter, B.S., Kevin M. Gutiérrez, M.A., José A. Cabriales, M.A., Ishmael I. Lopez, Ivan Torres B.A., & Theodore V. Cooper, Ph. D.

The University of Texas at El Paso

Table 2: Linear Regression predicting smoking status at 3 month follow-up

B SE B β 95% Confidence interval p

Lower Upper

Constant 2.45 .576

Smoking status

at baseline

.658 .084 .477 .492 .824 <.01*

Treatment

condition

-.307 .222 -.083 -.745 .131 .168

Age -.003 .008 -.024 -.018 .012 .702

Gender -.254 .227 -.068 -.701 .192 .263

Change in

drinking status

-.247 .107 -.139 -.457 -.037 .021*

* Denotes significant association with smoking status at 3 month follow-up

0

5

10

15

20

25

30

35

40

45

% o

f part

icip

ants

Figure 2 Drinking Status

Baseline

Follow-up

0

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10

15

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25

30

35

% o

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icip

ants

Figure 1 Smoking Status

Baseline

Follow-up