Stage of Change of Cigarette Smoking in Alcohol-Dependent Patients

Transcription

1 Special Topic Section Interdisciplinary Alcohol Research in Europe Editor: M. Krausz (Hamburg) Eur Addict Res 2000;6:84 90 Stage of Change of Cigarette Smoking in Alcohol-Dependent Patients Daniele Zullino a Jacques Besson b Christiane Schnyder b a Unité de biochimie et de psychopharmacologie clinique et b Section des dépendances, Département universitaire de psychiatrie adulte, Prilly-Lausanne, Switzerland Key Words Alcohol W Smoking W Smoking cessation W Motivation Abstract Despite the heavy burden of tobacco-related problems in alcohol-dependent patients, little effort has been directed toward reducing the prevalence of smoking in these patients. It seems reasonable to develop nicotine addiction treatments for alcohol-dependent patients based on the smoker s stage of change. To assess the stage of change for tobacco consumption and possible quitting barriers in alcohol-dependent patients, 88 consecutively admitted inpatients of a Swiss university-affiliated alcohol withdrawal clinic were interviewed with a semistructured schedule. More than half of the alcoholdependent smokers (50.7%) considered the possibility of smoking cessation or had already decided to stop, although the majority (83.1%) were highly dependent smokers. Positive reinforcers were factors influencing motivation both to stop smoking as well as to continue smoking, whereas negative reinforcers had no influence. As recovering alcoholic patients are often interested in smoking cessation and the introduction of nicotine treatment interventions has been shown not to jeopardize the outcome of alcohol treatment, alcohol treatment programs should include counseling for smoking cessation. Education and training for staff is essential, as their beliefs and habits remain an important barrier. Introduction Copyright 2000 S. Karger AG, Basel The co-occurrence of alcohol and tobacco consumption is well documented. Approximately 90% of alcoholic patients are smokers [1, 2]. More alcoholics than nonalcoholics are smokers [2, 3], and alcoholics smoke more heavily than nonalcoholic smokers [2, 4]. Moreover, alcohol-dependent smokers are more nicotine dependent than their nonalcoholic counterpart [2, 4, 5] and smokers have increased odds for alcohol disorders [6]. Finally, current alcoholic smokers and smokers with a history of alcohol disorder are more likely to have difficulty refraining from smoking [2, 4, 7]. On the other hand, smokers, whose alcohol abuse had remitted, are as likely to quit as smokers with no history of alcoholism. Discontinuation of alcohol abuse seems therefore to increase the potential for successful smoking cessation [8]. There are two general models which may explain these observations. One model assumes a common vulnerabili- ABC Fax karger@karger.ch S. Karger AG, Basel /00/ $17.50/0 Accessible online at: Dr. D. Zullino Unité de biochimie et de psychopharmacologie clinique Département universitaire de psychiatrie adulte Clinique de Cery, CH 1008 Prilly-Lausanne (Switzerland) Tel , Fax , Daniele.Zullino@inst.hospvd.ch

2 ty for both addictions. The second model presupposes that the abuse of one substance predisposes an individual to abuse the other. A variety of pharmacologic and nonpharmacologic mechanisms have been proposed which underlie the strong relationship between nicotine and alcohol abuse [3, 9 12]. Smoking has been suggested to influence the transition from moderate to excessive use of alcohol by diminishing feelings of alcohol intoxication [13]. Furthermore it has been proposed that different addictive behaviors may be powerful cues for each other, e.g. continued smoking may provide a stimulus for continued alcohol use [12]. Twin analyses have suggested that initiation of adolescent alcohol use and smoking may be influenced by the same shared environmental factors, whereas adult alcohol and tobacco use were associated with the shared genetic risk factors [14]. Since endogenous opioid peptides have been found to play an important role in alcohol as well as nicotine reinforcement [15], a reciprocal induction of addiction has been suggested at this level. Alcohol-dependent patients are at high risk of developing tobacco-related diseases because they are 2 3 times more likely to smoke than nonalcoholics. The correlation between smoking and drinking is of concern not only because of the independent health effects of such habits, but also because of possible synergistic effects. The allcause mortality in alcohol-dependent smokers is at least twice as high as that in nonalcoholic smokers [16, 17]. Alcohol and tobacco act synergistically to increase the risk of laryngeal, esophageal and oral cavity cancer. The combined health risks of smoking and drinking have been estimated to be 50% higher than the sum of their independent risks [2]. Despite the heavy burden of tobacco-related problems in alcohol-dependent patients, little effort has been directed toward reducing the prevalence of smoking in these patients. Alcohol treatment professionals are often reluctant to address tobacco dependence in their patients [11, 18, 19]. This attitude has developed out of fear that attempts at smoking cessation would be stressful and jeopardize the outcome of alcohol treatment. Other reasons have been staff smoking practices, the fear that programs might lose clients if treatment for tobacco dependence was included, a sense that smoking is a less important problem than other drugs, and, last but not least, tradition. Harmful consequences of other addictive disorders are often more immediately apparent than those of tobacco. Smoking in these patients may therefore be frequently defined as a minor problem. The concern about jeopardizing successful recovery due to excessive stress from attempting to quit both habits at once is at least plausible during alcohol detoxification. However, if applied much beyond this period, it is less convincing. Contrary to commonly held beliefs, recovering alcohol-dependent patients are often interested in receiving counseling for smoking cessation or treatment. Although their cessation rate may be lower than in nonalcoholic smokers [20], they can successfully stop smoking [11, 21]. Indeed it has repeatedly been shown that smoking cessation does not threaten sobriety [11, 22, 23] and may, in some cases, even raise the success rates of alcohol cessation [24]. Increasingly, effective nicotine addiction treatments are modeled to the specific smoking patterns as well as quitting motives and barriers of smokers in identified high-risk groups [20]. These are largely based on the model of Prochaska and DiClemente [25], who have suggested a sequence of natural states of change for quitting smokers. In the first stage, the precontemplation stage, the smoker is not thinking seriously about quitting. This first stage may be followed by a stage of planning to quit, the contemplation stage. After a third stage (determination stage), the patient may enter the action stage, which is characterized by preparations to quit and finally smoking cessation itself. It will be followed by a maintenance stage or eventually a relapse and recycling stage. One implication of this model is that individuals will be most receptive to interventions tailored to their particular stage of change. Precontemplators may be more responsive to motivational programs designed to move them into the contemplation stage and not respond to action strategies geared to immediate cessation. Determining motivational stage may therefore be critical to designing programs that will be effective with alcohol-dependent smokers. Hospital smoke-free policies are becoming increasingly common in the USA. The feasibility of a smoke-free policy and nicotine treatment programs in alcohol treatment programs has been proven [26]. After implementation of the policy, patients were more interested in quitting smoking and were more likely to abstain from smoking. Finally they no longer thought that quitting tobacco consumption would jeopardize alcohol abstinence [27]. Whereas a general trend toward smoking cessation can also be observed in Switzerland [28], smoking cessation and smoke-free policy remain taboo topics in the field of substance abuse treatment. In the present study we tried to assess the stage of change for tobacco consumption in alcohol-dependent patients attending a specialized hospital for alcohol withdrawal. Stage of Change of Smoking and Alcohol Dependency Eur Addict Res 2000;6:

3 Table 1. Characteristics of patients Females 31 (35.2%) Mean age, years 47.11B10.82 Numbers of hospitalizations for alcohol detoxification (mean) 1.96B1.05 First hospitalization for alcohol detoxification 61 (69.3%) Smoking status Never smoked 10 (11.4%) Former smoker 7 (8.0%) Current smoker 1 71 (80.7%) Smokes within 30 min of waking 59 (83.1%) Stage Precontemplation 30 (42.3%) Contemplation 33 (46.5%) Determination 3 (4.2%) Action 0 (0.0%) Relapse 5 (7.0%) Smoking-related problems Trouble breathing or shortness of breath 29 (40.8%) Frequent coughing 53 (74.6%) Getting tired in a short time 46 (64.8%) Pain or tightness in the chest 22 (31.0%) No symptoms 7 (9.9%) Quitting barriers Fear of failure 17 (23.9%) Irritability, nervousness 47 (66.2%) Difficulty concentrating 19 (26.8%) Craving 51 (71.8%) Loss of a pleasure 33 (46.5%) Weight gain 13 (18.3%) No quitting barrier 6 (8.5%) Expect help and understanding from family and/or friends 36 (50.7%) Other psychiatric diagnostics (DSM-IV) Alcohol-related disorders 15 (17.0%) Schizophrenic disorder 2 (2.3%) Depression, unipolar 15 (17.0%) Anxiety disorder 7 (8.0%) Personality disorder 41 (46.6%) Other dependencies 9 (10.2%) 1 n = Smokers = 71. Methodology Subjects were 88 consecutively admitted inpatients attending a university-affiliated alcohol withdrawal program (Clinique du Vallon, Lausanne). Patients were diagnosed according to DSM-IV. The recruitment took place between April and September After they had given their consent, all patients were assessed by two raters on the day of admission. A semistructured schedule was used, derived from the Smoking History Assessment Form [29], a practical smoking assessment form, containing the key items recommended by the American National Cancer Institute for studies of smoking cessation. The assessment form consists of: items rating the number of cigarettes smoked per day, time until the first cigarette of the day, serious attempt to quit in the past year, smoking-related symptoms, quitting barriers, past quitting attempts and a question about serious thoughts about quitting smoking in the next year. The time until the first cigarette of the day has been recommended as a reliable index of high nicotine dependence [30]. The items assessing recent attempts to quit and current readiness to quit were used to identify the smoker s stage of change. Smokers who were seriously thinking about stopping in the next year were defined as contemplators, while those who were not considering stopping were defined as precontemplators. Patients who had determined a date for a withdrawal attempt and had possibly already prepared cessation strategies (e.g. purchased nicotine replacement devices or selfhelp literature) were defined as being in the determination stage. A patient was considered to be in the action stage if he had recently stopped smoking and was still experiencing withdrawal symptoms. The stage of maintenance was defined as having stopped and no longer having withdrawal symptoms. Smokers with a serious attempt to quit in the past year (for at least 24 h) were finally regarded as being in the relapse stage. Several possible quitting barriers were assessed: fear of failure, expectation of nervousness or irritability, difficulty concentrating, craving, weight gain and losing a pleasure. An additional question asked about the expected support from family and friends in case of a quitting attempt. Tests of statistical significance were carried out with 2 tests to determine the differences between gender, degree of nicotine dependence, smoking-related health problems and quitting barriers with regard to the stage of change. The stages of contemplation and determination were collapsed into one group and the stages of relapse and precontemplation into a further one. As 2! 2 cross-tables resulted, continuity correction was performed. Results The characteristics of the patients included are listed in table 1. A total of 57 men and 31 women (mean age, B years) were included in the study. Of these, 61 attended the clinic for the first time. The remaining 27 (30.7%) had been hospitalized before (mean 1.38 B 0.67 times). At the time of admission to the clinic, 10 patients had never been smokers, 7 were former smokers and 71 reported current tobacco consumption. The majority (83.1%) of the smokers said they usually smoked within 30 min of waking. Smoking-Related Problems Almost all smokers (90.1%) reported on one or more of the inquired smoking-related symptoms. Trouble breathing or shortness of breath was reported by 29 of the smokers, frequent coughing by 53, getting tired in a short time by 46 and pain or tightness in the chest by Eur Addict Res 2000;6:84 90 Zullino/Besson/Schnyder

4 Table 2. Readiness to quit smoking by gender, nicotine dependence, smoking-related health problems and quitting barriers Relapse/ precontemplation n % Contemplation/ determination n % 2 p Gender Male n.s. Female Smokes within 30 min after awakening Yes n.s. No Smoking-related problems Shortness of breath Yes n.s. No Frequent coughing Yes n.s. No Tired in short time Yes n.s. No Pain in the chest Yes n.s. No Quitting barriers Fear of failure Yes n.s. No Irritability, nervousness Yes n.s. No Difficulty concentrating Yes n.s. No Craving Yes n.s. No Loss of a pleasure Yes p! 0.01 No Weight gain Yes n.s. No Help and understanding from friends or family Yes p! 0.01 No n = All actual smokers = 71. Quitting Barriers The majority of smokers (91.5%) anticipated difficulties associated with smoking cessation. When smokers were asked about the anticipated problems associated with a smoking cessation attempt, 17 (23.9%) of them responded fear of failure, 47 (66.2%) expected irritability, tension or nervousness, 19 (26.8%) difficulty concentrating, 51 (71.8%) craving, 33 (46.5%) said it would be a loss of a pleasure for them, and 13 (18.3%) feared weight gain. Stage of Change of Smoking and Alcohol Dependency Eur Addict Res 2000;6:

5 Approximately half of the smokers (50.7%) thought they could expect help and understanding from their family and/or friends if they tried to quit smoking. Stage of Change On the day of admission, 30 of the 71 smokers (42.3%) were classified as precontemplators, 33 (46.5%) as contemplators, 3 (4.2%) as being in the determination stage and 5 (7.0%) patients as being in the relapse stage. No patient was trying to stop smoking actively on the day of admission. Gender, nicotine dependence and smoking-related symptoms were not significantly associated with the stage of change (table 2). Of the examined quitting barriers, only the variable loss of pleasure differentiated between patients considering smoking cessation and those who did not consider stopping. Patients who designated losing a pleasure as an important quitting barrier, were less likely to be in the contemplation/determination group (33.3%) than patients who thought this should not be a substantial obstacle (65.8%). Those patients who reported possible help and understanding from friend or family members in case of a quitting attempt were more likely to be in the contemplation/determination group (69.4%) than the patients without support. Discussion Contrary to traditional beliefs, interest in smoking cessation is frequent in alcohol-dependent patients. In our survey, more than half of the alcohol-dependent smokers (50.7%) considered the possibility of smoking cessation or had already decided to stop, although the majority (83.1%) were highly dependent smokers, i.e. reported to smoke within 30 min of waking. Highly addicted smokers generally have severer withdrawal reactions and greater difficulty quitting. The impact of such quitting barriers on the stage of change seems, however, to be moderate. In our sample, the examined quitting barriers did not determine the proportion of smokers considering smoking cessation, with one exception. Patients who considered smoking cessation as a loss of a pleasure were more frequently precontemplators. Interestingly, this is the only one of the examined variables which can be considered as a positive reinforcement stimulus. A greater proportion of patients in the contemplation/ determination group than in the comparative group anticipated help and understanding from their entourage in the case of a cessation attempt. This variable too can be considered as a positive reinforcer. The examined negative reinforcers (i.e. the smoking-related symptoms), had no association with the stage of change. Therefore, positive reinforcers were factors influencing motivation both to stop smoking as well as to continue smoking, whereas negative reinforcers had no influence. However, the study may be limited by the small number of variables outlining smoking cessation barriers and motivations. Moreover, our inpatient sample may not be representative of recovering alcoholic patients in Switzerland as there are important differences between the different linguistic regions with regard to quantity of alcohol consumed, preference for the different beverages and the amount of alcohol consumed per drinking occasion [31]. Although the smoking-related problems did not influence the stage of change in our sample, the assessment of these symptoms may nevertheless be useful for therapeutic purposes. Amplifying awareness of smoking-related symptoms can raise quitting motivation. This can be reinforced by biofeedback methods like measures of alveolar carbon monoxide levels. Our stage of change data seem to be comparable to those previously observed in the USA, showing the high interest of alcohol-dependent patients in advice and assistance for smoking cessation. Bobo et al. [21] reported on both alcoholic outpatients and inpatients separately. In the study of 461 recovering alcohol-dependent outpatients, 64% were classified in the precontemplation stage and 28% were classified as being in contemplation. In the second study of 90 alcohol-dependent inpatients, 57% were classified in the precontemplation stage and 33% in contemplation. Although a great proportion of alcohol-dependent patients consider the possibility of attempting smoking cessation, they may find smoking cessation difficult during alcohol treatment. This leads to the belief of many alcohol disorder treatment professionals that addressing both dependencies simultaneously would jeopardize their success. The utility of addressing tobacco consumption in alcohol treatments has, however, been shown. Joseph et al. [32] reported a study on the effect of a smoking cessation intervention completed by a policy banning smoking. Ten percent of patients reported quitting smoking in the intervention group as compared to 4 % in the control group after more than a year of follow-up. No significant differences between the intervention and control group were observed for the rates of improvement of alcohol abuse. In a further study, Hurt et al. [22] examined the effect of 88 Eur Addict Res 2000;6:84 90 Zullino/Besson/Schnyder

6 nicotine dependence treatment on the 1-year outcome of 101 persons of an inpatient addiction treatment unit. The smoking cessation rate at 1 year was 11.8% in the intervention group and 0 in the control group. The intervention did not seem to interfere with either alcohol or drug abstinence. The 1-year relapse rate was 31.4% in the intervention group and 34% in controls. It seems reasonable to develop nicotine addiction treatments for alcohol-dependent patients based on the smoker s stage of change. The goal with precontemplators is to move them, over time, to contemplation and action stages by bolstering their quitting motivation and self-efficacy. The goal for the contemplators is to motivate and assist them to move to a determination to quit and then to take action and maintain abstinence. The goal for those in action is to assist them to quit smoking and to stay smoke free. The goal for those in maintenance stages is to help them consolidate a new nonsmoking life-style and to resist relapse cues and temptations. As minimal-contact quit smoking strategies have been reported to reduce tobacco consumption, increase longterm quit rates and prevent tobacco relapses in community populations [29], and to be feasible in alcohol-dependent patients [33], such interventions may be introduced in alcohol dependency programs without great costs. As alcoholic smokers are usually heavy nicotine users with higher levels of nicotine dependence, they might, however, need further support. They may especially benefit from nicotine replacement therapy [4, 34]. There has been only little debate in Switzerland about smoking-free policies in residential dependency treatment programs. Potential concerns about implementing smoke-free policies in alcohol inpatient treatment programs include potential patient noncompliance, the need to manage nicotine withdrawal symptoms and declining rates of admission for treatment because of smoking policy. Smoke-free hospital policies for inpatient substance abuse disorder treatment programs in the USA have been shown to be feasible and well accepted by patients and staff, and not to jeopardize alcohol treatment outcomes [19, 23]. In a study comparing the interest in quitting smoking before and after the implementation of a smoke-free policy in a residential substance dependency treatment program (treating drug and alcohol dependence simultaneously) Joseph [27] found that 24% of patients in the prepolicy group said they wanted to quit smoking during hospitalization. In the postpolicy group the percentage increased to 61%. Rates of early termination of treatment did not change in the two study periods. 41% of patients hospitalized before implementation of the smoke-free policy abstained from smoking for more than 1 week compared to 9% in the prepolicy group. The long-term treatment outcomes were not affected by including nicotine treatment interventions. The interventions were, however, associated with a small positive effect on selfreported smoking behavior. One important possible quitting barrier may be smoking staff as they will be less likely to urge cessation [19]. Therefore, education and training for staff becomes essential before implementing smoking cessation programs in this difficult-to-treat population [35]. In conclusion, recovering alcoholic patients are often interested in smoking cessation. Their stage of change seems to be influenced more by positive than by negative reinforcers. As the introduction of nicotine treatment interventions does not jeopardize the outcome of alcohol treatment, every alcoholic smoker should receive counseling for smoking cessation. Education and training for staff is essential, as their beliefs and habits remain an important barrier. References 1 Batel P, Pessione F, Maître C, Rueff B: Relationship between alcohol and tobacco dependencies among alcoholics who smoke. Addiction 1995;90: Bien TH, Burge R: Smoking and drinking: A review of the literature. Int J Addict 1990;25: Johnson KA, Jennison KM: The drinkingsmoking syndrome and social context. Int J Addict 1992;27: Hughes JR: Treatment of smoking cessation in smokers with past alcohol/drug problems. J Subst Abuse Treat 1993;10: Gulliver SB, Rohsenow DJ, Colby SM, Dey AN, Abrams DB, Niaura R, Monti PM: Interrelationship of smoking and alcohol dependence, use and urges to use. J Stud Alcohol 1995;56: Breslau N: Psychiatric comorbidity of smoking and nicotine dependence. Behav Genet 1995; 25: Murray RP, Istvan JA, Voelker HT, Rigdon MA, Wallace MD: Level of involvement with alcohol and success at smoking cessation in the Lung Health Study. J Stud Alcohol 1995;56: Breslau N, Peterson E, Schultz L, Andreski P, Chilcoat H: Are smokers with alcohol disorders less likely to quit? Am J Public Health 1996;86: Stage of Change of Smoking and Alcohol Dependency Eur Addict Res 2000;6:

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