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Concurrent treatment for alcohol and tobacco dependence: are patients ready to quit both?
Drug and Alcohol Dependence 69 (2003) 1 /7 www.elsevier.com/locate/drugalcdep
Concurrent treatment for alcohol and tobacco dependence: are patients ready to quit both? Angela L. Stotts *, Joy M. Schmitz, John Grabowski Department of Psychiatry and Behavioral Sciences, U.T. Mental Sciences Institute, Substance Abuse Research Center, University of Texas Medical School at Houston, 1300 Moursund Avenue, Houston, TX 77030, USA Received 4 February 2002; received in revised form 10 July 2002; accepted 19 July 2002
Abstract The prevalence of smoking among alcohol abusers is high, yet little is known about this dual-dependency. This study examines mechanisms involved in changing both alcohol and tobacco use concurrently using the transtheoretical model (TTM) measures of change. Alcohol and tobacco dependent outpatients (N /115) entering a dual-substance dependence program were compared on baseline measures of motivation, self-initiated change activities, and self-efficacy associated with each substance use behavior. Differences on these measures were expected for drinking versus smoking. Motivation to change each behavior was also examined as a potential predictor of retention in treatment. Results indicated that patients reported higher self-efficacy to abstain and lower temptation to use alcohol relative to cigarettes. Change activities were also initiated at higher levels for drinking compared with smoking. An interaction between drinking and smoking motivation for change was found in the prediction of treatment retention; those with higher motivation for changing their alcohol use and lower motivation to quit smoking remained longer in treatment, while those who were higher in motivation for changing both behaviors dropped out the earliest. Overall, participants in this dualdependence program were more confident and active in changing their alcohol use. Initiating cessation of both behaviors equally and simultaneously may prove difficult for this population. This study initiates an understanding of the mechanisms involved in changing alcohol /tobacco dependence and may provide guidance for developing dual cessation interventions. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Alcohol; Smoking; Dual-dependence; Motivation; Transtheoretical model
1. Introduction The prevalence of smoking among alcohol abusers is considerably higher than rates in the general population, 80 /90 and 25%, respectively (Batel et al., 1995; DiFranza and Guerrera, 1990; Hurt et al., 1996). Recent research has documented the strong association between alcohol and tobacco smoking. For example, smoking rate was positively correlated with amount of alcohol consumed and severity of alcohol dependence in alcohol treatment outpatients (Batel et al., 1995). Also, nicotine deprivation has been associated with increased urges to drink, cognitions regarding alcohol, and alcohol consumption in alcohol-abusing smokers (Palfai et al.,
* Corresponding author. Tel.: /1-713-500-2720; fax: /1-713-5002849 E-mail address: [email protected] (A.L. Stotts).
2000). It has also been found that individuals with a more severe alcohol dependency tend to be more nicotine dependent than less severe or non-drinkers, and their odds of smoking cessation are reduced (Daeppen et al., 2000; Dawson, 2000; Hurt et al., 1996). Despite the high concurrence of alcohol and tobacco dependence, alcohol treatment programs have been reluctant to promote smoking cessation, presumably because of lack of interest among patients or potential negative effects on alcohol treatment outcomes (Bobo and Gilchrist, 1983; Burling et al., 1997; Sees and Clark, 1993). Recent research has suggested otherwise, however, Ellingstad et al. (1999) reported that 77% of alcohol treatment-seeking individuals who were also smokers reported a willingness to consider stopping smoking during or after alcohol treatment. Further, initiating smoking cessation during or subsequent to alcohol treatment has not significantly jeopardized
03765-8716/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 6 - 8 7 1 6 ( 0 2 ) 0 0 2 2 7 - 2
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abstinence (Bobo et al., 1998; Burling et al., 2001; Burling, et al., 1991; Hurt et al., 1994). Smoking cessation interventions with current or past alcohol dependent individuals have met with limited success, however. Reductions in smoking tend to be small, short-term, and lower than those typically found with non-substance abusing populations (Bobo et al., 1998; Burling et al., 2001, 1991; Campbell, et al., 1995). Therefore, although alcohol and drug abusers may be interested and willing to participate in smoking cessation treatment, consistently positive smoking outcomes have yet to be achieved in these populations. Understanding and examining the process of change for both alcohol and smoking cessation has been a central focus of the Transtheoretical Model (TTM) (DiClemente and Prochaska, 1998; Prochaska and DiClemente, 1984). Three interrelated constructs, stages of change, processes of change (POC), and self-efficacy have been used to describe and predict smoking and drinking outcomes (Carbonari and DiClemente, 2000; Perz et al., 1996; Stotts et al., 2000, 2001). For example, stage or readiness for change was the strongest predictor of drinking behavior in the 1-year follow-up of a large alcohol treatment matching study (Project MATCH Research Group, 1997a). Stage of change also has been found to be a strong predictor of postpartum relapse to smoking (Stotts et al., 2000). Similarly, higher levels of process or change activity have been associated with increased motivation for change and positive smoking outcomes (DiClemente et al., 1991). The selfefficacy component of the TTM measures both confidence to resist drinking and temptation to drink, and has been found to be a robust predictor of both smoking and drinking outcomes (DiClemente et al., 1991; Project MATCH Research Group, 1997b). Numerous studies have evaluated the TTM variables related to changing smoking and drinking behaviors independently. However, none has examined these variables in the context of changing both concurrently. Based on past findings, it is expected that success in changing both behaviors will, in part, depend on relative levels of readiness, self-efficacy, and self-initiated change activity associated with each behavior. Understanding how these variables interact in alcohol /tobacco dependent patients may provide important information toward developing dual cessation interventions. This study compared baseline variables related to quitting drinking and smoking in outpatients entering a dual-substance dependence treatment program. It was hypothesized that the TTM variables of motivation to change, self-efficacy, temptation, and POC would be different for drinking versus smoking. Due to the traditional emphasis on alcohol treatment relative to smoking cessation, we expected that dual-dependent patients would be more ready to change their drinking behavior. In addition, although the treatment study for
which these data were collected is ongoing, preliminary retention data are presented as a function of baseline motivation to change. It was hypothesized that higher motivation to change both alcohol and nicotine use would be associated with longer retention in treatment.
2. Method 2.1. Research participants Participants (N /115) were consecutive admissions to the Treatment Research Clinic (TRC) in Houston, TX for a program targeting both alcohol and nicotine dependence concurrently. The TRC is a university medical center-based research facility and has been described elsewhere by Elk et al. (1993). To be included in this study, participants had to be English-speaking adults between the ages of 18 and 60, able to participate in 12 weeks of outpatient treatment, free of serious legal and medical problems, interested in quitting both drinking and smoking, and competent to give informed consent. 2.2. Measurement 2.2.1. Sociodemographics and substance use Author-constructed forms were used to collect sociodemographic and drug history information. The timeline follow back (TLFB: Sobell et al., 1996) interview was used at baseline to assess alcohol and cigarette use for the 90 days prior to intake. The TLFB facilitates enhanced recall of past substance use through a calendar-assisted structured interview and has been found to be the most reliable and valid method for assessing prior alcohol use (Sobell et al., 1979, 1980). 2.2.2. Diagnosis Current and past diagnostic information was obtained using the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) per the Structured Clinical Interview for DSM-IV (SCID: First et al., 1995). SCID assessments were conducted by masters and doctoral level clinicians who were trained by experienced interviewers using standardized training videotapes from Biometrics Research, NY. As recommended, a series of practice interviews was performed to enhance interrater reliability before beginning interviews with study participants. Provisional SCID-based diagnoses were confirmed by the study psychologist or psychiatrist. 2.2.3. Transtheoretical model measures The 32-item University of Rhode Island Change Assessment scale (URICA: McConnaughy et al., 1983) was used to measure motivation to change alcohol use.
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Good reliability, internal consistency, and discriminate and predictive validity have been demonstrated for this measure (DiClemente and Hughes, 1990). The internal consistency coefficient for the URICA scale in our sample was 0.79, with alpha coefficients of 0.80, 0.80, 0.84 and 0.84 for the precontemplation (PC), contemplation (C), action (A), and maintenance subscales, respectively. Subscales from the URICA were used to compute an alcohol readiness to change score, which has been shown to provide information consistent with traditional stage profiles (Carbonari et al., 1994). Readiness to change scores were calculated by summing the C, A, and maintenance means and then subtracting the PC mean. Motivation to change smoking behavior was measured using the TTM staging algorithm for smoking cessation (DiClemente et al., 1991). Four stages of change were defined as follows: (1) PC, i.e. not giving serious thought to quitting in the next 6 months; (2) C, i.e. giving serious thought to quitting in the next 6 months but not in the next 30 days, or planning to quit in the next 30 days but not making a quit attempt in the past year; (3) preparation (PA), i.e. giving serious thought to quitting in the next 30 days and having made a quit attempt; (4) A, i.e. quit smoking. Two parallel, 20-item POC scales (DiClemente et al., 1985), one for alcohol use and one for smoking, were used to measure the ten POC (i.e. activities related to change), as well as two higher-order factors, the experiential and behavioral POC. Experiential processes consist of cognitive and affective change activities, while behavioral processes refer to more active strategies. Subjects indicate the frequency of these 20 cognitive or behavioral change activities related to drinking alcohol or smoking cigarettes within the last month on a 5-point Likert scale from (1) never to (5) repeatedly. Coefficient alphas for the smoking and alcohol POC scales were 0.88 and 0.89, respectively. Abstinence self-efficacy scales (ASE: DiClemente et al., 1985) are self-rated, 20-item measures that assess confidence to abstain from substance use. Two ASE scales were administered, one for alcohol and one for smoking. Temptation scales measuring temptation to use alcohol or to use cigarettes under the same high-risk situations were also used. The ASE has demonstrated strong indices of reliability with a total score-alpha of 0.92 and a substantial negative correlation (/0.65) between the temptation and confidence scales (DiClemente et al., 1994). The internal consistency coefficients for the Smoking ASE and Temptation scales in our sample were 0.96 and 0.95, respectively. Alpha coefficients for the alcohol ASE and temptation scales were 0.95 and 0.94, respectively. 2.2.4. Substance severity The Alcohol Dependence Scale (ADS: Skinner and Horn, 1984) consists of 25-items and was used to assess
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physical and psychological components of alcohol dependence. Higher ADS scores are associated with greater severity of alcohol dependence. The Fagerstro¨m Tolerance Questionnaire (FTQ: Heatherton et al., 1991) was used to measure nicotine dependence. High nicotine dependence is usually defined as an FTQ score of 7 or higher of a possible maximum of 11 points (Heatherton et al., 1991). 2.3. Procedures Eligible participants were identified through an initial telephone screen routinely completed by those seeking outpatient treatment at the TRC. Informed consent was obtained after research staff met individually with each potential participant to confirm study eligibility and fully explain all procedures. Participants consented to participate in a 12-week medication and psychotherapy clinical trial for concurrent alcohol and tobacco dependence. Prior to treatment, participants were asked to complete a 3/5 day intake assessment which included a physical examination, laboratory work-up, HIV and TB testing, structured clinical interviews, and various selfreport measures. Reimbursement for travel to the clinic and for completion of study assessment procedures was provided at the rate of $5 per day. Following intake, participants were assigned randomly to a pharmacological treatment condition for alcohol (naltrexone or placebo) and for smoking (transdermal nicotine replacement or placebo) in this 2/2 clinical trial. In addition, all participants attended weekly individual behavioral therapy sessions targeting both drinking and smoking behaviors. Therapists and supervisors strived to ensure that there was equal treatment emphasis on the two behaviors. The medication and behavior therapy program was 12 weeks in duration. 2.4. Analysis Means (standard deviations) and frequencies were obtained on sociodemographic and drug history variables for the full alcohol/nicotine dependent sample (N /115). Correlational and x2 analyses were conducted to determine the degree of association between motivation to change alcohol use and motivation for smoking cessation. Separate two-tailed Student’s t-tests for correlated samples were used to detect differences between POC, ASE, and Temptation scores for smoking and for drinking. Experiential and Behavioral subscales of the POC were also examined using the same analytic procedures. As the underlying scale distributions for alcohol and smoking measures of the same construct may differ, non-parametric Wilcoxon signed ranks tests were also conducted for corroboration. Finally, analysis of covariance (ANCOVA) procedures were used to
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assess the effects of motivation to change alcohol and to change smoking on retention in treatment (number of sessions completed), while statistically controlling for three potentially confounding factors, treatment condition and alcohol and tobacco dependence severity (measured by the ADS and the FTND). Slight variation in sample size across analyses is due to attrition during the intake period.
3. Results 3.1. Sample characteristics Participants were an average (9/S.D.) age of 41.8 (9.4) and most were male (70%). Eighty-one percent were Caucasian, 10.4 and 8% were Africian/American and Hispanic, respectively. The average number of years of education was 14.2 (2.5) and 63.6% were employed. In the past 90 days, participants consumed alcohol on an average of 74 (20.1) days, with the mean number of standard drinks per drinking day being 9.1 (7.3). The average score on the ADS was 17.7 (7.9). With regard to nicotine, participants were smoking an average of 23.6 cigarettes each day and reported regular smoking for an average of 23.3 (10.3) years. The mean score on the FTND was 6.0 (2.5). 3.2. Motivation to change smoking and drinking Applying the smoking stages of change algorithm, one person was in PC, 43 were in C, 62 in PA, and four individuals were already in A. Due to small numbers in two of the stages participants were classified as either in a lower motivation (PC’s and C’s) or higher motivation (PA’s and A’s) group for changing their smoking. To facilitate meaningful interpretation of results, alcohol readiness to change scores were dichotomized at the median score (10.7) to obtain similar groups representing higher (n/50) and lower (n /56) motivation. Results indicated that alcohol and smoking motivation variables correlated in a negative direction (r //0.09), however, this association was not statistically significant. x2 Analyses also indicated no relationship between the two motivation variables. 3.3. Processes of change Significant differences were found on baseline POC scores for drinking and smoking (Fig. 1). Overall, participants were engaging in higher levels of process use for their alcohol problem relative to their smoking, t (108) /5.2, P B/0.00. Nonparametric analyses also resulted in significance, P B/0.00. Both experiential and behavioral processes were being used at higher levels for drinking than for smoking, t (108) /2.9, P B/
Fig. 1. Treatment-seeking outpatients who were dependent on both tobacco and alcohol were compared on baseline POC, self-efficacy (confidence), and temptation for drinking and for smoking. Mean scores indicate higher process (change) activity (P B/0.00) and confidence to abstain (P B/0.00), and lower temptation (P B/0.00) for drinking relative to smoking. Error bars/1 S.E.M.
0.01 and t (108) /6.2, P B/0.00, respectively, nonparametric tests were comparable, P B/0.003 and 0.00. 3.4. Self-efficacy to abstain/temptation to use Differences were found on ASE and temptation scores for drinking and smoking. Participants reported significantly greater confidence to refrain from drinking relative to smoking, t (108) /5.9, P /0.00 (Fig. 1). Similarly, temptation to drink was rated lower than temptation to smoke, t (108) /7.9, P /0.00 (Fig. 1). Nonparametric comparisons confirmed these results. 3.5. Motivation to change and treatment retention For those who initiated treatment (n /79), no main effects for motivation to change either alcohol or smoking were found on retention, F(1,78) /0.61, P / 0.44 and F (1,78) /1.2, P /0.28, respectively. However, a significant interaction was detected, F (1,78) /4.8, P B/0.05. As shown in Fig. 2, participants with higher
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Fig. 2. A significant difference in mean number of therapy sessions attended by tobacco /alcohol dependent outpatients was found as a function of an interaction between baseline motivation to change smoking and to change drinking (P B/0.05). Error bars/1 S.E.M.
motivation for changing their drinking and lower motivation for smoking cessation completed a greater number of treatment sessions. Those who reported higher motivation for changing both drinking and smoking behaviors completed the fewest sessions, followed by those who had lower motivation to quit both substances. A follow-up ANOVA procedure revealed no main effects for treatment group, nor a treatment by motivation interaction effect, on retention, indicating no differential influence of treatment group on retention. Also, no relationship was found between alcohol or tobacco dependence severity and treatment retention, F (1,78) /1.04, P /0.49, F (1,78) /1.6, P /0.20, respectively.
4. Discussion Although the alcohol /tobacco dependent patients in this study expressed an interest in quitting both substances, results indicated clear differences in their attitudes, beliefs, and behaviors associated with each. These dual-dependent patients reported higher selfefficacy to abstain and lower temptation to use alcohol relative to cigarettes. In addition, at baseline they had initiated change processes at higher levels for their alcohol problem compared with smoking. In addition, an interesting interaction between drinking and smoking motivation for change was found in the prediction of
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one indirect measure of treatment outcome. Treatment retention was better for those with higher motivation for quitting drinking and lower motivation to quit smoking, and worse for those with high initial motivation to quit both substances. The pattern of results across the TTM variables suggests that, although the alcohol /tobacco treatment program emphasized the two substances equally, participants who entered the program tended to be more engaged in the process of changing their drinking than their smoking behavior (DiClemente et al., 1991; Prochaska et al., 1991). Confidence or self-efficacy to abstain from alcohol was higher, which is regarded a positive prognostic indicator for treatment success, i.e. advancing through the stages of change and maintaining abstinence (DiClemente et al., 1985). Also of significance are the higher levels of cognitive and behavioral process activity for alcohol relative to cigarette use upon entering the program, indicating that patients were more actively modifying aspects of their drinking behavior compared with their smoking. The lack of relationship between baseline smoking and drinking motivation to change is difficult to interpret. Perhaps questionnaire responses were somewhat biased due to required eligibility criteria, i.e. a stated interest in quitting both alcohol and cigarette use. The differing psychometric properties of the two instruments measuring motivation may also have introduced measurement error, thereby, inflating the Type II error rate. It is certainly possible, however, that dual-dependent patients may experience the two substance use problems as separate, and that motivation to address one truly has no bearing on motivation to work on the other. Regardless, remaining measures indicated that overall patients appeared more confident, interested, and engaged in the process of changing their drinking relative to smoking. These results may offer an explanation, in part, for the low cessation rates in smokers with current or past histories of alcohol dependence (Bobo et al., 1998; Burling et al., 2001, 1991; Campbell et al., 1995). This study has particular relevance for developing treatment approaches for alcohol /tobacco dependent patients, i.e. should the treatments be concurrent, sequential, or not at all linked? Ellingstad et al. (1999) reported that the majority of alcoholic smokers in their study indicated a preference for smoking cessation treatment after undergoing alcohol treatment or not at all. Data from the current study indicate that patients who reported a higher desire to address both substance dependencies tended to drop from treatment earlier than those who placed more emphasis on one behavior (i.e. drinking) over the other. It is possible that those who dropped out of treatment early may have been experiencing treatment success and believed that completing the treatment program was unnecessary. Dropping out of treatment, however, is typically not associated with
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long-term treatment success (Baekeland and Lundwall, 1975). Therefore, despite participants’ stated interests in quitting both substances, changing both behaviors concurrently may have been excessively taxing, both psychologically and physiologically. A recent laboratory study of hazardous drinkers who smoked (Palfai et al., 2000) lends support to this hypothesis in that nicotine deprivation was found to place hazardous drinkers at risk for increased alcohol consumption. The authors suggested that efforts to restrict smoking may lead to higher levels of alcohol use during early attempts to quit smoking. Thus, it is possible that restricting two reinforcers simultaneously may lead to poor treatment outcome. We must reiterate, however, that this study was able only to address outcome indirectly via retention and not directly with substance use data. Also, there are studies suggesting that smoking cessation during or subsequent to alcohol treatment does not appear to jeopardize abstinence (e.g. Burling et al., 2001). Further study of the mechanisms underlying alcohol /tobacco cessation patterns, as well as treatment sequencing effects on outcome, is needed before conclusions can be drawn. Limitations to this study are noted. Although we recruited widely in a large, ethnically diverse city, the resulting sample was primarily white and male. Thus, results may not generalize to the full population of alcohol /tobacco dependent individuals; nor are these results likely to generalize to inpatients or to those dependent on only one substance. Also, the motivation measures for alcohol and smoking abstinence were in different formats (scale vs. algorithm), making direct comparison a challenge. Finally, these data were collected as part of an ongoing treatment study, and, therefore, only one indirect measure of treatment outcome (retention) could be reported. Future studies need to replicate and further explore these findings, especially as they relate to substance use outcomes. Studies testing various treatment approaches for dual-dependent patients are also needed, specifically to determine the optimal manner in which to present treatments for two (or more) substance use problems. Finally, for many alcohol /nicotine dependent patients, less initial effort is being expended for smoking cessation and self-efficacy for smoking abstinence is low. Thus, novel methods for increasing motivation and efficacy for smoking cessation in this population are needed.
Acknowledgements This research was supported by a National Institute of Alcoholism and Alcohol Abuse grant (#AA1121603). We would also like to acknowledge Shelly Sayre and Patti Hokanson for their contributions to the data collection/management aspects of this paper.
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Concurrent treatment for alcohol and tobacco dependence: are patients ready to quit both? Angela L. Stotts *, Joy M. Schmitz, John Grabowski Department of Psychiatry and Behavioral Sciences, U.T. Mental Sciences Institute, Substance Abuse Research Center, University of Texas Medical School at Houston, 1300 Moursund Avenue, Houston, TX 77030, USA Received 4 February 2002; received in revised form 10 July 2002; accepted 19 July 2002
Abstract The prevalence of smoking among alcohol abusers is high, yet little is known about this dual-dependency. This study examines mechanisms involved in changing both alcohol and tobacco use concurrently using the transtheoretical model (TTM) measures of change. Alcohol and tobacco dependent outpatients (N /115) entering a dual-substance dependence program were compared on baseline measures of motivation, self-initiated change activities, and self-efficacy associated with each substance use behavior. Differences on these measures were expected for drinking versus smoking. Motivation to change each behavior was also examined as a potential predictor of retention in treatment. Results indicated that patients reported higher self-efficacy to abstain and lower temptation to use alcohol relative to cigarettes. Change activities were also initiated at higher levels for drinking compared with smoking. An interaction between drinking and smoking motivation for change was found in the prediction of treatment retention; those with higher motivation for changing their alcohol use and lower motivation to quit smoking remained longer in treatment, while those who were higher in motivation for changing both behaviors dropped out the earliest. Overall, participants in this dualdependence program were more confident and active in changing their alcohol use. Initiating cessation of both behaviors equally and simultaneously may prove difficult for this population. This study initiates an understanding of the mechanisms involved in changing alcohol /tobacco dependence and may provide guidance for developing dual cessation interventions. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Alcohol; Smoking; Dual-dependence; Motivation; Transtheoretical model
1. Introduction The prevalence of smoking among alcohol abusers is considerably higher than rates in the general population, 80 /90 and 25%, respectively (Batel et al., 1995; DiFranza and Guerrera, 1990; Hurt et al., 1996). Recent research has documented the strong association between alcohol and tobacco smoking. For example, smoking rate was positively correlated with amount of alcohol consumed and severity of alcohol dependence in alcohol treatment outpatients (Batel et al., 1995). Also, nicotine deprivation has been associated with increased urges to drink, cognitions regarding alcohol, and alcohol consumption in alcohol-abusing smokers (Palfai et al.,
* Corresponding author. Tel.: /1-713-500-2720; fax: /1-713-5002849 E-mail address: [email protected] (A.L. Stotts).
2000). It has also been found that individuals with a more severe alcohol dependency tend to be more nicotine dependent than less severe or non-drinkers, and their odds of smoking cessation are reduced (Daeppen et al., 2000; Dawson, 2000; Hurt et al., 1996). Despite the high concurrence of alcohol and tobacco dependence, alcohol treatment programs have been reluctant to promote smoking cessation, presumably because of lack of interest among patients or potential negative effects on alcohol treatment outcomes (Bobo and Gilchrist, 1983; Burling et al., 1997; Sees and Clark, 1993). Recent research has suggested otherwise, however, Ellingstad et al. (1999) reported that 77% of alcohol treatment-seeking individuals who were also smokers reported a willingness to consider stopping smoking during or after alcohol treatment. Further, initiating smoking cessation during or subsequent to alcohol treatment has not significantly jeopardized
03765-8716/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 6 - 8 7 1 6 ( 0 2 ) 0 0 2 2 7 - 2
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abstinence (Bobo et al., 1998; Burling et al., 2001; Burling, et al., 1991; Hurt et al., 1994). Smoking cessation interventions with current or past alcohol dependent individuals have met with limited success, however. Reductions in smoking tend to be small, short-term, and lower than those typically found with non-substance abusing populations (Bobo et al., 1998; Burling et al., 2001, 1991; Campbell, et al., 1995). Therefore, although alcohol and drug abusers may be interested and willing to participate in smoking cessation treatment, consistently positive smoking outcomes have yet to be achieved in these populations. Understanding and examining the process of change for both alcohol and smoking cessation has been a central focus of the Transtheoretical Model (TTM) (DiClemente and Prochaska, 1998; Prochaska and DiClemente, 1984). Three interrelated constructs, stages of change, processes of change (POC), and self-efficacy have been used to describe and predict smoking and drinking outcomes (Carbonari and DiClemente, 2000; Perz et al., 1996; Stotts et al., 2000, 2001). For example, stage or readiness for change was the strongest predictor of drinking behavior in the 1-year follow-up of a large alcohol treatment matching study (Project MATCH Research Group, 1997a). Stage of change also has been found to be a strong predictor of postpartum relapse to smoking (Stotts et al., 2000). Similarly, higher levels of process or change activity have been associated with increased motivation for change and positive smoking outcomes (DiClemente et al., 1991). The selfefficacy component of the TTM measures both confidence to resist drinking and temptation to drink, and has been found to be a robust predictor of both smoking and drinking outcomes (DiClemente et al., 1991; Project MATCH Research Group, 1997b). Numerous studies have evaluated the TTM variables related to changing smoking and drinking behaviors independently. However, none has examined these variables in the context of changing both concurrently. Based on past findings, it is expected that success in changing both behaviors will, in part, depend on relative levels of readiness, self-efficacy, and self-initiated change activity associated with each behavior. Understanding how these variables interact in alcohol /tobacco dependent patients may provide important information toward developing dual cessation interventions. This study compared baseline variables related to quitting drinking and smoking in outpatients entering a dual-substance dependence treatment program. It was hypothesized that the TTM variables of motivation to change, self-efficacy, temptation, and POC would be different for drinking versus smoking. Due to the traditional emphasis on alcohol treatment relative to smoking cessation, we expected that dual-dependent patients would be more ready to change their drinking behavior. In addition, although the treatment study for
which these data were collected is ongoing, preliminary retention data are presented as a function of baseline motivation to change. It was hypothesized that higher motivation to change both alcohol and nicotine use would be associated with longer retention in treatment.
2. Method 2.1. Research participants Participants (N /115) were consecutive admissions to the Treatment Research Clinic (TRC) in Houston, TX for a program targeting both alcohol and nicotine dependence concurrently. The TRC is a university medical center-based research facility and has been described elsewhere by Elk et al. (1993). To be included in this study, participants had to be English-speaking adults between the ages of 18 and 60, able to participate in 12 weeks of outpatient treatment, free of serious legal and medical problems, interested in quitting both drinking and smoking, and competent to give informed consent. 2.2. Measurement 2.2.1. Sociodemographics and substance use Author-constructed forms were used to collect sociodemographic and drug history information. The timeline follow back (TLFB: Sobell et al., 1996) interview was used at baseline to assess alcohol and cigarette use for the 90 days prior to intake. The TLFB facilitates enhanced recall of past substance use through a calendar-assisted structured interview and has been found to be the most reliable and valid method for assessing prior alcohol use (Sobell et al., 1979, 1980). 2.2.2. Diagnosis Current and past diagnostic information was obtained using the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) per the Structured Clinical Interview for DSM-IV (SCID: First et al., 1995). SCID assessments were conducted by masters and doctoral level clinicians who were trained by experienced interviewers using standardized training videotapes from Biometrics Research, NY. As recommended, a series of practice interviews was performed to enhance interrater reliability before beginning interviews with study participants. Provisional SCID-based diagnoses were confirmed by the study psychologist or psychiatrist. 2.2.3. Transtheoretical model measures The 32-item University of Rhode Island Change Assessment scale (URICA: McConnaughy et al., 1983) was used to measure motivation to change alcohol use.
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Good reliability, internal consistency, and discriminate and predictive validity have been demonstrated for this measure (DiClemente and Hughes, 1990). The internal consistency coefficient for the URICA scale in our sample was 0.79, with alpha coefficients of 0.80, 0.80, 0.84 and 0.84 for the precontemplation (PC), contemplation (C), action (A), and maintenance subscales, respectively. Subscales from the URICA were used to compute an alcohol readiness to change score, which has been shown to provide information consistent with traditional stage profiles (Carbonari et al., 1994). Readiness to change scores were calculated by summing the C, A, and maintenance means and then subtracting the PC mean. Motivation to change smoking behavior was measured using the TTM staging algorithm for smoking cessation (DiClemente et al., 1991). Four stages of change were defined as follows: (1) PC, i.e. not giving serious thought to quitting in the next 6 months; (2) C, i.e. giving serious thought to quitting in the next 6 months but not in the next 30 days, or planning to quit in the next 30 days but not making a quit attempt in the past year; (3) preparation (PA), i.e. giving serious thought to quitting in the next 30 days and having made a quit attempt; (4) A, i.e. quit smoking. Two parallel, 20-item POC scales (DiClemente et al., 1985), one for alcohol use and one for smoking, were used to measure the ten POC (i.e. activities related to change), as well as two higher-order factors, the experiential and behavioral POC. Experiential processes consist of cognitive and affective change activities, while behavioral processes refer to more active strategies. Subjects indicate the frequency of these 20 cognitive or behavioral change activities related to drinking alcohol or smoking cigarettes within the last month on a 5-point Likert scale from (1) never to (5) repeatedly. Coefficient alphas for the smoking and alcohol POC scales were 0.88 and 0.89, respectively. Abstinence self-efficacy scales (ASE: DiClemente et al., 1985) are self-rated, 20-item measures that assess confidence to abstain from substance use. Two ASE scales were administered, one for alcohol and one for smoking. Temptation scales measuring temptation to use alcohol or to use cigarettes under the same high-risk situations were also used. The ASE has demonstrated strong indices of reliability with a total score-alpha of 0.92 and a substantial negative correlation (/0.65) between the temptation and confidence scales (DiClemente et al., 1994). The internal consistency coefficients for the Smoking ASE and Temptation scales in our sample were 0.96 and 0.95, respectively. Alpha coefficients for the alcohol ASE and temptation scales were 0.95 and 0.94, respectively. 2.2.4. Substance severity The Alcohol Dependence Scale (ADS: Skinner and Horn, 1984) consists of 25-items and was used to assess
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physical and psychological components of alcohol dependence. Higher ADS scores are associated with greater severity of alcohol dependence. The Fagerstro¨m Tolerance Questionnaire (FTQ: Heatherton et al., 1991) was used to measure nicotine dependence. High nicotine dependence is usually defined as an FTQ score of 7 or higher of a possible maximum of 11 points (Heatherton et al., 1991). 2.3. Procedures Eligible participants were identified through an initial telephone screen routinely completed by those seeking outpatient treatment at the TRC. Informed consent was obtained after research staff met individually with each potential participant to confirm study eligibility and fully explain all procedures. Participants consented to participate in a 12-week medication and psychotherapy clinical trial for concurrent alcohol and tobacco dependence. Prior to treatment, participants were asked to complete a 3/5 day intake assessment which included a physical examination, laboratory work-up, HIV and TB testing, structured clinical interviews, and various selfreport measures. Reimbursement for travel to the clinic and for completion of study assessment procedures was provided at the rate of $5 per day. Following intake, participants were assigned randomly to a pharmacological treatment condition for alcohol (naltrexone or placebo) and for smoking (transdermal nicotine replacement or placebo) in this 2/2 clinical trial. In addition, all participants attended weekly individual behavioral therapy sessions targeting both drinking and smoking behaviors. Therapists and supervisors strived to ensure that there was equal treatment emphasis on the two behaviors. The medication and behavior therapy program was 12 weeks in duration. 2.4. Analysis Means (standard deviations) and frequencies were obtained on sociodemographic and drug history variables for the full alcohol/nicotine dependent sample (N /115). Correlational and x2 analyses were conducted to determine the degree of association between motivation to change alcohol use and motivation for smoking cessation. Separate two-tailed Student’s t-tests for correlated samples were used to detect differences between POC, ASE, and Temptation scores for smoking and for drinking. Experiential and Behavioral subscales of the POC were also examined using the same analytic procedures. As the underlying scale distributions for alcohol and smoking measures of the same construct may differ, non-parametric Wilcoxon signed ranks tests were also conducted for corroboration. Finally, analysis of covariance (ANCOVA) procedures were used to
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assess the effects of motivation to change alcohol and to change smoking on retention in treatment (number of sessions completed), while statistically controlling for three potentially confounding factors, treatment condition and alcohol and tobacco dependence severity (measured by the ADS and the FTND). Slight variation in sample size across analyses is due to attrition during the intake period.
3. Results 3.1. Sample characteristics Participants were an average (9/S.D.) age of 41.8 (9.4) and most were male (70%). Eighty-one percent were Caucasian, 10.4 and 8% were Africian/American and Hispanic, respectively. The average number of years of education was 14.2 (2.5) and 63.6% were employed. In the past 90 days, participants consumed alcohol on an average of 74 (20.1) days, with the mean number of standard drinks per drinking day being 9.1 (7.3). The average score on the ADS was 17.7 (7.9). With regard to nicotine, participants were smoking an average of 23.6 cigarettes each day and reported regular smoking for an average of 23.3 (10.3) years. The mean score on the FTND was 6.0 (2.5). 3.2. Motivation to change smoking and drinking Applying the smoking stages of change algorithm, one person was in PC, 43 were in C, 62 in PA, and four individuals were already in A. Due to small numbers in two of the stages participants were classified as either in a lower motivation (PC’s and C’s) or higher motivation (PA’s and A’s) group for changing their smoking. To facilitate meaningful interpretation of results, alcohol readiness to change scores were dichotomized at the median score (10.7) to obtain similar groups representing higher (n/50) and lower (n /56) motivation. Results indicated that alcohol and smoking motivation variables correlated in a negative direction (r //0.09), however, this association was not statistically significant. x2 Analyses also indicated no relationship between the two motivation variables. 3.3. Processes of change Significant differences were found on baseline POC scores for drinking and smoking (Fig. 1). Overall, participants were engaging in higher levels of process use for their alcohol problem relative to their smoking, t (108) /5.2, P B/0.00. Nonparametric analyses also resulted in significance, P B/0.00. Both experiential and behavioral processes were being used at higher levels for drinking than for smoking, t (108) /2.9, P B/
Fig. 1. Treatment-seeking outpatients who were dependent on both tobacco and alcohol were compared on baseline POC, self-efficacy (confidence), and temptation for drinking and for smoking. Mean scores indicate higher process (change) activity (P B/0.00) and confidence to abstain (P B/0.00), and lower temptation (P B/0.00) for drinking relative to smoking. Error bars/1 S.E.M.
0.01 and t (108) /6.2, P B/0.00, respectively, nonparametric tests were comparable, P B/0.003 and 0.00. 3.4. Self-efficacy to abstain/temptation to use Differences were found on ASE and temptation scores for drinking and smoking. Participants reported significantly greater confidence to refrain from drinking relative to smoking, t (108) /5.9, P /0.00 (Fig. 1). Similarly, temptation to drink was rated lower than temptation to smoke, t (108) /7.9, P /0.00 (Fig. 1). Nonparametric comparisons confirmed these results. 3.5. Motivation to change and treatment retention For those who initiated treatment (n /79), no main effects for motivation to change either alcohol or smoking were found on retention, F(1,78) /0.61, P / 0.44 and F (1,78) /1.2, P /0.28, respectively. However, a significant interaction was detected, F (1,78) /4.8, P B/0.05. As shown in Fig. 2, participants with higher
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Fig. 2. A significant difference in mean number of therapy sessions attended by tobacco /alcohol dependent outpatients was found as a function of an interaction between baseline motivation to change smoking and to change drinking (P B/0.05). Error bars/1 S.E.M.
motivation for changing their drinking and lower motivation for smoking cessation completed a greater number of treatment sessions. Those who reported higher motivation for changing both drinking and smoking behaviors completed the fewest sessions, followed by those who had lower motivation to quit both substances. A follow-up ANOVA procedure revealed no main effects for treatment group, nor a treatment by motivation interaction effect, on retention, indicating no differential influence of treatment group on retention. Also, no relationship was found between alcohol or tobacco dependence severity and treatment retention, F (1,78) /1.04, P /0.49, F (1,78) /1.6, P /0.20, respectively.
4. Discussion Although the alcohol /tobacco dependent patients in this study expressed an interest in quitting both substances, results indicated clear differences in their attitudes, beliefs, and behaviors associated with each. These dual-dependent patients reported higher selfefficacy to abstain and lower temptation to use alcohol relative to cigarettes. In addition, at baseline they had initiated change processes at higher levels for their alcohol problem compared with smoking. In addition, an interesting interaction between drinking and smoking motivation for change was found in the prediction of
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one indirect measure of treatment outcome. Treatment retention was better for those with higher motivation for quitting drinking and lower motivation to quit smoking, and worse for those with high initial motivation to quit both substances. The pattern of results across the TTM variables suggests that, although the alcohol /tobacco treatment program emphasized the two substances equally, participants who entered the program tended to be more engaged in the process of changing their drinking than their smoking behavior (DiClemente et al., 1991; Prochaska et al., 1991). Confidence or self-efficacy to abstain from alcohol was higher, which is regarded a positive prognostic indicator for treatment success, i.e. advancing through the stages of change and maintaining abstinence (DiClemente et al., 1985). Also of significance are the higher levels of cognitive and behavioral process activity for alcohol relative to cigarette use upon entering the program, indicating that patients were more actively modifying aspects of their drinking behavior compared with their smoking. The lack of relationship between baseline smoking and drinking motivation to change is difficult to interpret. Perhaps questionnaire responses were somewhat biased due to required eligibility criteria, i.e. a stated interest in quitting both alcohol and cigarette use. The differing psychometric properties of the two instruments measuring motivation may also have introduced measurement error, thereby, inflating the Type II error rate. It is certainly possible, however, that dual-dependent patients may experience the two substance use problems as separate, and that motivation to address one truly has no bearing on motivation to work on the other. Regardless, remaining measures indicated that overall patients appeared more confident, interested, and engaged in the process of changing their drinking relative to smoking. These results may offer an explanation, in part, for the low cessation rates in smokers with current or past histories of alcohol dependence (Bobo et al., 1998; Burling et al., 2001, 1991; Campbell et al., 1995). This study has particular relevance for developing treatment approaches for alcohol /tobacco dependent patients, i.e. should the treatments be concurrent, sequential, or not at all linked? Ellingstad et al. (1999) reported that the majority of alcoholic smokers in their study indicated a preference for smoking cessation treatment after undergoing alcohol treatment or not at all. Data from the current study indicate that patients who reported a higher desire to address both substance dependencies tended to drop from treatment earlier than those who placed more emphasis on one behavior (i.e. drinking) over the other. It is possible that those who dropped out of treatment early may have been experiencing treatment success and believed that completing the treatment program was unnecessary. Dropping out of treatment, however, is typically not associated with
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long-term treatment success (Baekeland and Lundwall, 1975). Therefore, despite participants’ stated interests in quitting both substances, changing both behaviors concurrently may have been excessively taxing, both psychologically and physiologically. A recent laboratory study of hazardous drinkers who smoked (Palfai et al., 2000) lends support to this hypothesis in that nicotine deprivation was found to place hazardous drinkers at risk for increased alcohol consumption. The authors suggested that efforts to restrict smoking may lead to higher levels of alcohol use during early attempts to quit smoking. Thus, it is possible that restricting two reinforcers simultaneously may lead to poor treatment outcome. We must reiterate, however, that this study was able only to address outcome indirectly via retention and not directly with substance use data. Also, there are studies suggesting that smoking cessation during or subsequent to alcohol treatment does not appear to jeopardize abstinence (e.g. Burling et al., 2001). Further study of the mechanisms underlying alcohol /tobacco cessation patterns, as well as treatment sequencing effects on outcome, is needed before conclusions can be drawn. Limitations to this study are noted. Although we recruited widely in a large, ethnically diverse city, the resulting sample was primarily white and male. Thus, results may not generalize to the full population of alcohol /tobacco dependent individuals; nor are these results likely to generalize to inpatients or to those dependent on only one substance. Also, the motivation measures for alcohol and smoking abstinence were in different formats (scale vs. algorithm), making direct comparison a challenge. Finally, these data were collected as part of an ongoing treatment study, and, therefore, only one indirect measure of treatment outcome (retention) could be reported. Future studies need to replicate and further explore these findings, especially as they relate to substance use outcomes. Studies testing various treatment approaches for dual-dependent patients are also needed, specifically to determine the optimal manner in which to present treatments for two (or more) substance use problems. Finally, for many alcohol /nicotine dependent patients, less initial effort is being expended for smoking cessation and self-efficacy for smoking abstinence is low. Thus, novel methods for increasing motivation and efficacy for smoking cessation in this population are needed.
Acknowledgements This research was supported by a National Institute of Alcoholism and Alcohol Abuse grant (#AA1121603). We would also like to acknowledge Shelly Sayre and Patti Hokanson for their contributions to the data collection/management aspects of this paper.
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