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. 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. 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.

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. 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 identified themselves 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 to 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 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.

Survey Results

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 undetectable 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 > .05). Sex-specific quit rates were 9% for males and 6% for females (P > .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 (ie, persons who had quit smoking but had relapsed back to tobacco smoking by follow-up) were combined with successful quitters. A quit attempt of more than 24 hours was reported by 45% of the study sample; 25% of all participants reported quitting for more than 7 days sometime during the year of follow-up. Quit attempt rates for participants from the smoking-cessation and usual-care treatment centers were similar (P > .05).

Race/ethnicity was the only sociodemographic variable significantly associated with attempts to quit smoking (P < .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 more than 24 hours and having quit for more than 7 days.

Of the participants who reported having quit smoking for more than 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 > .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.

Editorial Note from the CDC

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 more than 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.

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 more than 18 years old. 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; 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 (eg, income, education, occupation, and community traditions).

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. However, this position has not been substantiated by rigorous trials or investigation. In the study described in this report, recover