Addressing Heavy Drinking in Smoking Cessation Treatment: A Randomized Clinical Trial.

The positive association between cigarette smoking and alcohol use has been well documented (e.g., Chiolero, Wietlisbach, Ruffieux, Paccaud, & Cornuz, 2006; Dawson, 2000; Falk, Yi, & Hiller-Sturmhofel, 2006; Friedman, Tekawa, Klatsky, Sidney, & Armstrong, 1991). Almost 20% of current smokers consume five or more drinks on one occasion at least once per month, compared to about 6.5% of nonsmokers (Dawson, 2000). The combined negative effects of excessive drinking and smoking on health outcomes are substantial. For example, smoking and heavy drinking combine to produce especially negative consequences on brain morphology and function (Durazzo, Cardenas, Studholme, Weiner, & Meyerhoff, 2007; Meyerhoff et al., 2006), and smoking negates the cardioprotective effects of regular drinking (Ebbert, Janney, Sellers, Folsom, & Cerhan, 2005; Schroder, Marrugat, Elosua, & Covas, 2002). Furthermore, a multiplicative effect operates when smoking is combined with heavy drinking, conferring markedly greater risk for oral, pharyngeal, laryngeal, and esophageal cancers relative to just smoking, just drinking, or neither smoking nor drinking (Pelucchi, Gallus, Garavello, Bosetti, & La Vecchia, 2006). Greater alcohol use is associated with decreased odds of smoking cessation (Hymowitz et al., 1997; Osler, Prescott, Godtfredsen, Hein, & Schnohr, 1999; Sorlie & Kannel, 1990; Zimmerman, Warheit, Ulbrich, & Buhl Auth, 1990) and is a strong prospective predictor of smoking relapse among self-quitters (Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992; Ockene et al., 2000). Current alcohol use (Humfleet, Munoz, Sees, Reus, & Hall, 1999; Sherman, Wang, & Nguyen, 1996; Smith, Kraemer, Miller, Debusk, & Taylor, 1999) and current binge drinking (Murray, Istvan, Voelker, Rigdon, & Wallace, 1995) at the start of a smoking cessation treatment and use of alcohol after treatment (Humfleet et al., 1999) are negatively associated with abstinence, although there has been an exception (Hughes & Oliveto, 1993). In treatment samples, approximately one quarter of smoking lapses occur in contexts involving alcohol use (Baer & Lichtenstein, 1988; Borland, 1990; Shiffman, 1982). A number of recent clinical trials have examined smoking cessation interventions initiated during alcoholism treatment. Results have indicated that these interventions do not harm treatment outcome and may even be associated with better drinking outcomes (Prochaska, Delucchi, & Hall, 2004), though there have been exceptions (e.g., Joseph, Willenbring, Nugent, & Nelson, 2004). However, relatively little attention has been devoted to smokers who drink heavily but are not alcohol dependent. The U.S. Department of Health and Human Services guidelines for treating tobacco dependence recommend that smokers reduce or avoid drinking alcohol as much as possible when making a quit attempt (Fiore, Bailey, Cohen, & et al., 2000). However, clinicians currently have little guidance as to how to address heavy drinking in smoking cessation treatment as no empirical studies have been published to date in this area. Brief motivationally-focused behavioral interventions have been shown to reduce drinking (McCrady, 2000; Moyer, Finney, Swearingen, & Vergun, 2002; Whitlock, Polen, Green, Orleans, & Klein, 2004) among drinkers who are not seeking treatment for alcohol problems and especially among those with less severe alcohol problems (Moyer et al., 2002). Incorporating brief interventions into smoking cessation treatment for nondependent heavy drinkers may be efficacious both in reducing drinking and in improving smoking cessation outcomes. Towards this end, the aim of the current study was to test the efficacy of a smoking cessation treatment that incorporated a brief alcohol intervention, which focused on the risks of smoking relapse associated with drinking and the negative effects of continued heavy drinking. This randomized clinical trial involved 236 non-alcohol dependent, heavy drinking smokers who were recruited from the community and were seeking smoking cessation treatment. Participants were randomized to either standard smoking cessation treatment (ST), which included provision of the nicotine patch, or an equivalent standard treatment that also incorporated a brief alcohol intervention (ST-BI). Treatment conditions were matched on amount of contact time and participants were followed for 26 weeks after their smoking quit date. We hypothesized that ST-BI, compared to ST, would result in higher rates of point prevalence smoking abstinence at 2, 8, 16, and 26 weeks after quit date and a lower number of alcoholic drinks consumed per week. In addition, we hypothesized that ST-BI, relative to ST, would result in lower rates of initial lapses to smoking that involved alcohol use during treatment. Finally, we examined two potential moderators of treatment effects on smoking: level of drinking prior to treatment and intention to change drinking. These analyses were considered exploratory as there are theoretical reasons to expect either stronger or weaker effects of ST-BI at higher levels of each variable. For pretreatment drinking, the emphasis of ST-BI on alcohol use might be especially relevant for relatively heavier drinkers; on the other hand, asking these very heavy drinkers to change both drinking and smoking simultaneously might prove overly difficult. For intention to change drinking, ST-BI might be relatively more effective for those who intend to change drinking because it reinforces the expectations of such smokers that changing alcohol use may facilitate smoking cessation; on the other hand, ST-BI could be less effective for these smokers because the information in ST-BI is redundant with their intentions.