Abstract
Aims:
Three smoking cessation studies (CARE, Break Free, Por Nuestra Salud [PNS]) were used to measure changes in average alcohol consumption, binge drinking and alcohol-related problems during a smoking cessation attempt and to explore co-action with smoking abstinence.
Design:
CARE and PNS were longitudinal cohort cessation studies; Break Free was a two-arm randomized clinical trial.
Setting:
Texas, USA.
Participants:
Participants were current smokers who were recruited from the community and received smoking cessation interventions. All participants received nicotine replacement therapy and smoking cessation counseling. CARE included 424 smokers (1/3 White, 1/3 African American and 1/3 Latino); Break Free included 399 African American smokers; PNS included 199 Spanish-speaking Mexican-American smokers.
Measurements:
Weekly alcohol consumption was collected multiple times pre and post-quit, and binge drinking and alcohol-related problems were collected at baseline and 26 weeks post-quit. Analyses included only those who indicated current alcohol use.
Findings:
Average alcohol consumption decreased from baseline to 26 weeks post-quit in CARE (F = 17.09, P < 0.001), Break Free (F = 12.08, P < 0.001) and PNS (F = 10.21, P < 0.001). Binge drinking decreased from baseline to 26 weeks post-quit in CARE (F = 3.94, P = 0.04) and Break Free (F = 10.41, P < 0.001) but not PNS. Alcohol-related problems decreased from baseline to 26 weeks post-quit in CARE (Chi-sq = 6.41, P = 0.010) and Break Free (Chi sq = 14.44, P = 0.001), but not PNS.
Conclusions:
Among current drinkers, alcohol use/problems appear to decrease during a smoking cessation attempt and remain low through 26 weeks after the quit attempt. Little evidence was found for co-action, with smoking abstainers and relapsers showing similar change in alcohol use/problems.
Keywords: alcohol use, binge drinking, co-action, problematic drinking, race/ethnicity, smoking cessation
INTRODUCTION
Tobacco remains the leading cause [1] and alcohol the third leading cause of preventable death and disability in the United States [2]. Moreover, co-use of tobacco and alcohol has a synergistic adverse effect on health, with co-use increasing the risk for morbidity and mortality over and above the use of either substance alone [3–5]. Co-use clusters together within both individuals (e.g. smokers are more likely to drink, binge drink and misuse alcohol than non-smokers) [6–8] and situations (e.g. co-use often happens within the same day and the same use episode) [9–12]. However, the consequences of cigarette smoking, alcohol use and their co-use can be ameliorated by quitting smoking and consuming less alcohol [13–15].
Theory and research on multiple health-risk behaviors highlight the importance of understanding the degree to which a change in one risky health behavior (e.g. attempt to quit smoking) induces changes in another [16, 17]. Here, we investigate (1) changes in alcohol use during a smoking quit attempt; and (2) co-action, defined as the degree to which a successful versus an unsuccessful change in smoking (e.g. smoking abstinence versus relapse) is associated with a change in alcohol use. Understanding co-action and changes in alcohol use during a smoking cessation attempt has the potential to contribute to the development of targeted interventions [17, 18].
There are several reasons to expect a change in alcohol use among smokers trying to quit. One hypothesis is that alcohol use increases during a quit attempt to combat nicotine withdrawal [19]. Quitting smoking is associated with increases in negative affect and stress, which may increase alcohol use [20–23]. In addition, quitting smoking is associated with a decrease in dopamine levels, which contributes to withdrawal symptoms [24], whereas alcohol use can increase dopamine levels [25–27].
Attempting to quit smoking may reduce alcohol use, and strategies used while quitting smoking may extend to alcohol use. For instance, avoiding locations associated with smoking may also decrease exposure to alcohol (e.g. bars, parties) [28]. Smoking acts as a behavioral cue for drinking such that quitting smoking may reduce cues for drinking [29], leading to a decrease in alcohol use. Smokers who know that drinking increases smoking urges might reduce alcohol use to decrease craving for cigarettes [30–33]. Finally, smokers trying to quit may be motivated to live healthier and drink less [17].
Unfortunately, most smoking cessation attempts fail [34], and relapse may impact alcohol use during a cessation attempt. Returning to smoking may decrease stress and/or increase dopamine levels, which decreases the desire to drink [20, 24] or smoking resumption may expose one to drinking cues and increase their alcohol use [29, 32, 33].
Prior research on co-action of smoking and alcohol use during a smoking cessation attempt
Two smoking cessation studies have examined smoking abstinence as a moderator of change in alcohol use during a smoking cessation attempt with mixed findings. One study found that abstainers showed a larger decrease in alcohol consumption and heavy drinking than did relapsers [35]. Another study found that compared to women who relapsed, men who remained quit for a year decreased alcohol consumption. Women showed a decrease in alcohol use at a year follow-up regardless of abstinence status [36].
Other studies found no evidence of co-action. A study with HIV+ smokers found no association of smoking status with alcohol use, but abstinence was defined as quitting smoking for even 1 day, which is a non-standard definition of quitting [10]. Among light smokers, alcohol consumption and binge drinking decreased after quitting smoking, but no difference was found between smoking abstainers and relapsers 6 months post-quit day [37]. Another cessation study found alcohol consumption decreased for the 2 weeks post-quit day, but no difference was found between abstainers and relapsers [19]. Additional studies measuring alcohol use during a smoking cessation attempt have also found decreases in alcohol use, but these studies did not examine whether decreases differed by smoking abstinence status [38–41].
Several conclusions can be drawn from prior research. First, evidence supports a potential decrease in alcohol consumption and binge drinking during a smoking cessation attempt with no identified studies indicating an increase in alcohol use. Second, studies examining co-action of smoking cessation with alcohol use found inconsistent results, with abstainers showing greater drops in alcohol use than relapsers in some studies, but not others. Therefore, it is unclear if decreases in alcohol use during a smoking cessation attempt occur regardless of smoking abstinence status or whether there is co-action, with decreases in alcohol use being higher among smoking abstainers than relapsers.
Although valuable, prior research examining co-action of smoking cessation and alcohol use is limited. Several studies exploring co-action examined very specific populations including the homeless [35], light smokers [37] and HIV+ smokers [10], whose results may not generalize to broader populations. Two other studies that examined co-action either examined alcohol use for only 2 weeks following quit day [19] or examined populations that were largely White (83%, 96%) [19, 36].
The goal of the current research was to examine co-action of abstinence status and alcohol use during a smoking cessation attempt among relatively large, diverse samples of adult smokers. Data from three smoking cessation studies were used to examine changes in alcohol use during a smoking quit attempt and to test for moderation by smoking abstinence. Gender and race/ethnicity were also tested as potential moderators. This research expands on past work by (1) examining three different measures of alcohol use (average weekly alcohol consumption, binge drinking, and alcohol-related problems); (2) examining moderation by smoking abstinence at both early and long-term post-quit follow-ups (the first several weeks and 26 weeks post-quit); and (3) including multiple studies with racially/ethnically diverse samples.
METHOD
Procedures
Participants
Data were collected as part of three separate smoking cessation studies: CARE, Break Free and Por Nuestra Salud (PNS). All participants were recruited in the Houston, Texas area. Approval was received from the Institutional Review Board of the University of Texas MD Anderson Cancer Center. Informed consent was obtained from all participants. The analysis was not pre-registered and the results should be considered exploratory.
CARE was a longitudinal cohort study examining the social determinants of smoking cessation. Participant recruitment and the study procedures have been reported elsewhere [42, 43]. Eligibility criteria included age 21 or older, ≥5 cigarettes/day and motivated to quit smoking within 30 days.
Break Free was a two-arm randomized clinical trial evaluating the efficacy of a palmtop computer-delivered smoking cessation intervention among African American smokers (both conditions were included in the present analysis). Participant recruitment and the study procedures have been reported elsewhere [44]. Eligibility criteria included age 21 to 65, ≥5 cigarettes/day and motivated to quit smoking within 2 weeks.
PNS was a longitudinal cohort study examining the social determinants of smoking cessation among Spanish-speaking individuals of Mexican heritage. Participant recruitment and the study procedures have been reported elsewhere [45]. Eligibility criteria included age 18 to 65, self-reported Mexican heritage, prefer to speak in Spanish, ≥5 cigarettes/day and motivated to quit smoking within 30 days.
All three studies shared similar exclusionary criteria: contraindication for nicotine patch use, active substance use dependence (including alcohol dependence and excluding nicotine), regular use of tobacco products other than cigarettes, use of other smoking cessation medications, pregnancy, participated in a smoking cessation program or study during the past 90 days or another household member enrolled.
Smoking cessation treatment
Participants from all three studies received 4 to 6 weeks of nicotine patches. Counseling is described in more detail below for each study. Note that none of the studies explicitly addressed alcohol use (i.e. it was not a module or pre-specified aspect of the intervention) unless it was relevant to that participant. For instance, if someone indicated that alcohol use was a trigger for smoking, it was then discussed.
In CARE, participants also received six counseling sessions based on the Treating Tobacco Use and Dependence Clinical Practice Guideline [34] and self-help materials [43]. Counseling sessions lasted 10 to 20 min. In-person sessions occurred 1 week before quit day, on quit day and at weeks 1, 2 and 4 post-quit. A telephone counseling session occurred 3 weeks post-quit.
Break Free participants were randomly assigned to standard cessation treatment or the standard treatment supplemented with treatment delivered via palmtop computer (computer-delivered treatment [CDT] condition) [44]. Standard treatment included culturally sensitive self-help materials (Pathways to Freedom) [46], and five in-person counseling sessions based on the Treating Tobacco Use and Dependence Clinical Practice Guideline [34]. In-person sessions were provided 12 and 5 days pre-quit day and at 3, 10 and 31 days post-quit day, and each session lasted 15 to 30 min. The CDT condition included everything the standard condition provided, in addition to 6 weeks of CDT, which began 12 days pre-quit day and continued to 31 days post-quit day.
In PNS, participants received cessation treatment that included Spanish-language self-help materials (Guia Para Dejar de Fumar) [47], and three brief in-person and three telephone counseling sessions based on an empirically validated intervention for Spanish-speaking smokers [48]. In-person counseling sessions occurred 1 week before quit day, on quit day and 3 weeks after. Telephone counseling sessions, which were conducted in Spanish and lasted about 15 min, occurred 3 days, 1 week and 2 weeks post-quit.
Measures
Analyses included individuals who endorsed drinking alcohol (i.e. those reporting no alcohol use were excluded). Alcohol users were identified by the following questions: CARE and Break Free—‘What is the maximum number of drinks you have consumed on any one occasion in the past 3 months?’ (must select 1 or more drinks); PNS—‘Do you ever drink alcohol?’ (must have indicated yes).
Alcohol use measures
Weekly alcohol consumption
Participants completed the Alcohol Quantity and Frequency Questionnaire, self-reporting how many standard alcoholic drinks they consumed on average each day of the week (e.g. ‘How many drinks do you consume on an average Monday’). These daily averages were summed to create an average number of drinks consumed per week [49]. Weekly alcohol consumption was collected as follows: CARE—baseline, quit day and 4 and 26 weeks post-quit; Break Free—baseline and 4.5 and 26 weeks post-quit; and PNS—baseline, quit day and 3 and 26 weeks post-quit.
Binge drinking
In CARE, participants responded to: ‘How often in the past three months have you consumed 5 or more drinks’. In Break Free, participants responded to: ‘How often (or how many occasions) in the past three months have you consumed 5 or more drinks?’ In PNS, participants responded to: ‘How often in the past 30 days have you consumed (4 if female; 5 if male) or more drinks?’ In all three studies, binge drinking was measured at baseline and 26 weeks post-quit [50].
Hazardous and harmful alcohol use (alcohol-related problems used here)
Participants in all three studies completed the alcohol module of the Patient Health Questionnaire (PHQ) [51]. Participants indicated if they ever drank alcohol followed by five questions asking if they had experienced a negative event associated with drinking (e.g. drunk or hungover at work, drove drunk) in the last 3 months. A positive response to one or more questions indicates hazardous and harmful alcohol use (note that the original PHQ uses the term ‘probable alcohol abuse’, but we have modified this to ‘hazardous and harmful alcohol use’ to be current with recent terminology; for ease of reading, this will be termed ‘alcohol-related problems’ throughout the article). In all three studies, alcohol-related problems were measured at baseline and 26 weeks post-quit.
Smoking status
Abstinence was defined in all studies as no smoking beginning on the quit date, verified by expired carbon monoxide level ≤10 ppm [52] or salivary cotinine value <20 ng/mL [53, 54]. Both an intention-to-treat (ITT) approach (participants lost to follow-up coded as relapsed), and a completers-only approach (participants lost to follow-up coded as missing), were used in the analyses. Relapse was not modeled as time-varying. Once a participant was classified as relapsed at one time point that status carried over to all subsequent time points. Smoking abstinence was analyzed at both early (4 weeks post-quit in CARE, 4.5 weeks in Break Free and 3 weeks in PNS) and long-term (26 weeks post-quit) follow-ups.
Time
Time was examined as a categorical variable. For the alcohol consumption analyses, four time points were examined in CARE and PNS (CARE: baseline [1-week pre-quit date], quit day, week 4 and week 26; PNS: baseline [1-week pre-quit date], quit day, week 3 and week 26) and three in Break Free (baseline [19 days pre-quit date], week 4.5 and week 26). For the binge drinking and alcohol-related problems analyses, baseline and week 26 were used in analyses for all three datasets.
Analysis plan
Three sets of longitudinal analyses were conducted for each dataset. Age, gender, race/ethnicity (in CARE), partner status, education level, cigarettes per day, time to first cigarette on waking and experimental condition (in Break Free) were included as covariates. Although we report results including current alcohol drinkers only here, we ran another set of analyses with the entire sample (i.e. drinkers and non-drinkers). Results were remarkably similar between the two sets of analyses.
The first set of analyses examined weekly alcohol consumption using mixed linear modeling with Proc Mixed in SAS (Enterprise Guide, Vers 6.1). These analyses used a categorical time variable to predict weekly alcohol consumption. Weekly alcohol consumption was skewed and kurtotic in all three datasets. Therefore, the weekly alcohol consumption measure was log transformed in CARE, Break Free and PNS, which helped normalize the variable.
The second set of analyses examined change in binge drinking from baseline to 26 weeks with generalized estimating equations using Proc Mixed in SAS (Enterprise Guide, Vers 6.1). Binge drinking was kurtotic and was log transformed in all datasets, which helped normalize the variable. Proc Mixed in SAS can analyze longitudinal data with multiple time points without dropping participants who have missing data at some time points [55]. Therefore, as binge drinking was collected at two time points, participants were retained in the analyses even if they had missing binge drinking data.
The third set of analyses examined change in the percentage meeting alcohol-related problems criteria from baseline to week 26. Generalized estimating equation analyses were conducted using Proc Genmod in SAS (Enterprise Guide, Vers 6.1) using a binomial distribution. Only participants who provided alcohol-related problems data at both baseline and week 26 were included in these analyses.
Covariates
Covariates were collected at baseline. Baseline smoking (i.e. average cigarettes smoked per day, time to first cigarette on waking [<5 min vs >5 min] [56]) and demographic (i.e. age, gender, relationship status, education level and race/ethnicity) measures were included as covariates in the statistical models examining alcohol consumption, binge drinking and alcohol-related problems in all three datasets. Treatment condition was also included as a covariate in all statistical models for Break Free.
Co-action analyses
For each of the above sets of analyses, smoking abstinence status (abstinent or relapsed) was tested as a moderator of differences in the alcohol use variables over time. Moderation was tested by both abstinence as measured at the early follow-up (week 4 in CARE, week 4.5 in Break Free and week 3 in PNS) and the long-term follow-up (week 26 in all data sets).
For alcohol consumption, if a significant interaction was found between time and abstinence status (early or long-term), a targeted contrast was completed comparing the pre-quit measures (baseline and quit day; baseline only in Break Free) versus the appropriate alcohol consumption measure post-quit day (week 4 in CARE, week 4.5 in Break Free and week 3 in PNS for early follow-up and week 26 for long-term follow-ups). For binge drinking and alcohol-related problems, abstinence status at both the early and long-term follow-up were tested as moderators of change from baseline to week 26. Results for analyses examining abstinence using the ITT and completers-only principles led to similar conclusions. Therefore, only the moderation by ITT abstinence results are presented.
Moderation by race and gender
For each data set, gender was tested as a moderator. In CARE, race/ethnicity was also examined as a moderator. All moderation analyses controlled for the other covariates. Note that these moderation analyses may be underpowered to detect significant effects.
RESULTS
Participant characteristics
In CARE, 424 participants were enrolled, but after excluding non-drinkers, 284 were included in the weekly alcohol consumption analyses. Of these 284, 29% (83) were non-Latino White, 31% (89) were African American and 40% (112) were Latino. Participants were included in binge drinking and alcohol-related problems analyses if they provided data at both baseline and week 26. In CARE, 281 participants provided binge drinking data and 284 provided alcohol-related problems data at both time points.
In Break Free, 399 African Americans were enrolled, but after excluding non-drinkers, 273 were included in the weekly alcohol consumption and probable alcohol abuse analyses. Binge drinking outcomes were available from 270 participants.
In PNS, 199 participants were enrolled, but after excluding non-drinkers, 170 were included in the weekly alcohol consumption and alcohol-related problems analyses. Binge drinking outcomes were available from 158 participants.
Regarding tobacco abstinence data, in CARE, there were 46 participants with missing data at week 4 and 44 participants with missing data at week 26. In Break Free, there were 49 participants missing abstinence data at week 4.5 and 42 participants with missing data at week 26. In PNS, 25 participants were missing abstinence data at week 3 and 32 participants were missing data at week 26. Table 1 presents descriptive statistics and abstinence percentages for all three studies.
TABLE 1.
Participant characteristics for CARE, Break Free and PNS.
| CARE | Break Free | PNS | |
|---|---|---|---|
| Age | 39.6 (11.5) | 40.6 (10.0) | 37.1 (10.1) |
| Gender (% female) | 52% | 54% | 34% |
| Education (% > high school) | 60% | 48% | 24% |
| Partner status (% married/living with partner) | 37% | 42% | 68% |
| % smoking within 5 min of waking | 60% | 57% | 17% |
| Baseline cigarettes per day | 20.3 (10.6) | 20.6 (12.8) | 16.0 (8.4) |
| Early abstinence (ITT) | 15% | 8% | 21% |
| Early abstinence (completers) | 18% | 10% | 25% |
| Late abstinence (ITT) | 4% | 3% | 5% |
| Late abstinence (completers) | 4% | 4% | 9% |
| Weekly alcohol consumption | |||
| Baseline | |||
| Mean | 11.63 (14.86) | 13.62 (22.75) | 10.82 (19.72) |
| Median | 6 | 7 | 4 |
| Range | 0–94 | 0–250 | 0–150 |
| Quit day | |||
| Mean | 10.38 (14.25) | – | 9 (16.81) |
| Median | 6 | – | 2 |
| Range | 0–102 | – | 0–86 |
| Week 4 (abstainers) | |||
| Mean | 8.20 (12.45) | 16.86 (24.73) | 7.69 (15.39) |
| Median | 3 | 11 | 0.5 |
| Range | 0–60 | 0–71 | 0–66 |
| Week 4 (relapsers) | |||
| Mean | 8.05 (11.76) | 9.18 (11.76) | 5.64 (9.80) |
| Median | 5 | 5 | 1 |
| Range | 0–86 | 0–62 | 0–61 |
| Week 26 (abstainers) | |||
| Mean | 4.90 (4.72) | 4.5 (6.59) | 14.88 (21.38) |
| Median | 2.5 | 1.5 | 4 |
| Range | 0–15 | 0–16 | 0–64 |
| Week 26 (relapsers) | |||
| Mean | 9.02 (12.68) | 10.10 (10.85) | 6.11 (13.05) |
| Median | 4 | 6.5 | 1 |
| Range | 0–66 | 0–47 | 0–92 |
Note: Early abstinence refers to abstinence collected in the immediate weeks post-quit day (CARE: 4 weeks; Break Free: 4.5 weeks; PNS: 3 weeks). Late abstinence refers to abstinence collected at Week 26 post-quit. Completers refer to only participants who completed the assessment.
Abbreviations: ITT, intention to treat; PNS, Por Nuestra Salud.
Alcohol consumption analyses
In CARE, significant differences were found between alcohol consumption at different time points, with alcohol consumption at baseline significantly higher than alcohol consumption at quit day, week 4 and week 26 (see Table 2, Model 1A). Additional comparisons indicated that weekly alcohol consumption on quit day was significantly higher than at week 4 (t(275) = 3.82, P < 0.001) and week 26 (t(275) = 3.75, P < 0.001) post-quit. The week 4 and week 26 post-quit measures were not significantly different from each other (t(275) = −1.08, P = 0.28). Figure 1 presents results of the adjusted means.
TABLE 2.
Mixed linear analyses to predict weekly alcohol consumption.
| Predictors | β (SE) | 95% CI | P | df | F | P |
|---|---|---|---|---|---|---|
| CARE | Model 1A | |||||
| Time variable | 3, 275 | 17.09 | <0.001 | |||
| Intercept | 2.00 (3.29) | (1.39, 2.61) | <0.001 | |||
| Quit day | −0.13 (0.53) | (−0.21, −0.04) | 0.003 | |||
| Week 4 post-quit | −0.31 (0.58) | (−0.41, −0.21) | <0.001 | |||
| Week 26 post-quit | −0.38 (0.71) | (−0.51, −0.25) | <0.001 | |||
| Break Free | Model 1B | |||||
| Time variable | 2, 265 | 12.08 | <0.001 | |||
| Intercept | 2.68 (0.41) | (1.87, 3.50) | <0.001 | |||
| Week 4.5 post-quit | −0.31 (0.07) | (−0.44, −0.18) | <0.001 | |||
| Week 26 post-quit | −0.28 (0.09) | (−0.45, −0.11) | 0.002 | |||
| PNS | Model 1C | |||||
| Time variable | 3, 162 | 10.21 | <0.001 | |||
| Intercept | 1.28 (0.42) | (0.44, 2.12) | <0.001 | |||
| Quit day | −0.19 (0.07) | (−0.32, −0.06) | 0.004 | |||
| Week 3 post-quit | −0.43 (0.08) | (−0.58, −0.27) | <0.001 | |||
| Week 26 post-quit | −0.34 (0.10) | (−0.54, −0.14) | 0.001 |
Note: In all three data sets, the baseline time point is the comparison group for the time variable results. F and the corresponding P provide results for the type III tests of the significance for the time categorical variable fixed effect.
Abbreviation: PNS, Por Nuestra Salud.
FIGURE 1.
Adjusted log transformed means for alcohol consumption over time. The vertical axis indicates the average number of drinks (log transformed) per week that participants reported.
In Break Free’s preliminary analyses, the experimental treatment variable (CDT vs. no CDT) did not predict weekly alcohol consumption nor did it interact with time, therefore, the condition was only included as a covariate. The time variable was significant, and week 4.5 and week 26 alcohol consumption were both significantly lower than at baseline (Table 2, Model 1B). Follow-up analyses indicated that week 4.5 and week 26 weekly alcohol consumption were not significantly different from each other (t(265) = −0.33, P = 0.74) (see Figure 1 for graph of adjusted means).
In PNS, the time effect was a significant predictor (Table 2, Model 1C) with alcohol consumption at quit day, week 3 and week 26 significantly lower than at baseline. Follow-up analyses indicated that weekly alcohol consumption at week 3 was significantly lower than quit day (t(162) = 3.60, P < 0.001). Weekly alcohol consumption at week 26 was not significantly lower than quit day consumption (t(162) = 1.60, P = 0.11). Week 3 and 26 alcohol consumption were also not significantly different from each other (t(162) = −0.92, P = 0.36) (see Figure 1 for graph of adjusted means).
Binge drinking analyses
The next set of analyses used the categorical time variable (baseline and week 26) and covariates to predict binge drinking. In CARE, the time variable was a significant predictor (see Table 3, Model 2A) of binge drinking. In Break Free, the experimental condition variable did not predict binge drinking or interact with time, therefore, condition was only included as a covariate. The time variable was a significant predictor (see Table 3, Model 2B). The significant time effect found in CARE and Break Free indicated a decrease in binge drinking from baseline to 26 weeks post-quit. For PNS, the time variable was not a significant predictor (F(1, 161) = 0.14, P = 0.71). See Figure 2 for graphs of adjusted means.
TABLE 3.
Mixed linear analyses to predict binge drinking.
| Predictors | β (SE) | 95% CI | P | df | F | P |
|---|---|---|---|---|---|---|
| CARE | Model 2A | |||||
| Time variable | 1, 274 | 3.94 | 0.04 | |||
| Intercept | 1.28 (0.26) | (0.77, 1.80) | <0.001 | |||
| Week 26 post-quit | −0.14 (0.07) | (−0.28, −0.01) | 0.04 | |||
| Break Free | Model 2B | |||||
| Time variable | 1, 263 | 10.41 | 0.001 | |||
| Intercept | 1.64 (0.32) | (1.00, 2.27) | <0.001 | |||
| Week 26 post-quit | −0.22 (0.07) | (0.08, 0.34) | 0.001 | |||
| PNS | Model 2C | |||||
| Time variable | 1, 161 | 1.14 | 0.29 | |||
| Intercept | 0.29 (0.30) | (−0.30, 0.90) | 0.33 | |||
| Week 26 post-quit | 0.08 (007) | (−0.70, 0.22) | 0.29 |
Note: F and the corresponding P provide results for the type III tests of the significance for the time categorical variable fixed effect.
Abbreviation: PNS, Por Nuestra Salud.
FIGURE 2.
Adjusted log transformed binge drinking episodes over time. The vertical axis indicates the number of times (log transformed) participants reported binge drinking in the last 3 months for CARE and Break Free or in the last month for Por Nuestra Salud (PNS).
Alcohol-related problems analyses
The next set of analyses used the time variable and covariates to predict alcohol-related problems. In CARE, the time variable was a significant predictor (estimate = 0.43 (0.17), 95% CI = −0.09, 0.77, P = 0.01), indicating that the percentage of participants with alcohol-related problems decreased from baseline to week 26. In Break Free, the experimental condition did not predict alcohol-related problems nor did it interact with time, therefore, condition was only included as a covariate. The time variable was significant (estimate = 0.77 (0.21), 95% CI = 0.36, 1.18, P < 0.001), indicating a decrease in the percentage of participants with alcohol-related problems from baseline to week 26. In PNS, the time variable was non-significant (estimate = 0.11 (0.25), 95% CI = −0.37, 59, P = 0.65). See Figure 3 and Table 4 for alcohol-related problems results.
FIGURE 3.
Adjusted percentages for alcohol-related problems over time. The vertical axis indicates the percentage of participants who met criteria for alcohol-related problems at each time point.
TABLE 4.
Generalized estimating equation to predict alcohol-related problems.
| Predictors | β (SE) | 95% CI | P | df | χ2 | P |
|---|---|---|---|---|---|---|
| CARE | Model 3A | |||||
| Time variable | 1 | 6.41 | 0.01 | |||
| Intercept | 0.11 (0.63) | (−1.10, 1.32) | 0.86 | |||
| Week 26 post-quit | 0.43 (0.17) | (0.09, −0.77) | 0.01 | |||
| Break Free | Model 3B | |||||
| Time variable | 1 | 14.44 | 0.001 | |||
| Intercept | 0.58 (0.78) | (−0.97, 2.12) | 0.46 | |||
| Week 26 post-quit | 0.77 (0.21) | (0.36, 1.18) | 0.001 | |||
| PNS | Model 3C | |||||
| Time variable | 1 | 0.20 | 0.65 | |||
| Intercept | −1.15 (0.87) | (−2.84, 0.55) | 0.18 | |||
| Week 26 post-quit | 0.11 (0.24) | (−0.37, 0.59) | 0.65 |
Note: F and the corresponding P provide results for the type III tests of the significance for the time categorical variable fixed effect.
Abbreviation: PNS, Por Nuestra Salud.
Co-action analyses
Co-action analyses were performed using both early abstinence status and late abstinence status as moderators of the time variable predicting alcohol consumption, binge drinking and alcohol-related problems in CARE, Break Free and PNS. In total, 18 co-action moderation analyses were performed; two (early and late abstinence status) each for alcohol consumption, binge drinking and probable alcohol use for each of the three data sets. Of the 18 co-action analyses, all of the interactions of time and abstinence status (i.e. the effect of time was not moderated by abstinence status) were non-significant (all P >0.25), except for late abstinence status moderating the time variable predicting alcohol consumption in Break Free. For this analysis, ITT abstinence from week 26 post-quit was added as a predictor along with time and the covariates. Week 26 ITT abstinence was a non-significant (F(1, 264) = 0.55, P = 0.50) predictor of weekly alcohol consumption. Next, the interaction between abstinence status and time was added to the model and it was significant (F(2, 264) = 5.29, P = 0.005). Pair-wise comparisons indicated that weekly alcohol consumption was not significantly different between smokers who remained abstinent at week 26 and smokers who lapsed by week 26 at either baseline or week 3. However, abstainers reported significantly fewer drinks per week than abstainers at 26 weeks post-quit (t = −2.11, P = 0.03). For relapsers, their weekly alcohol consumption increased significantly from baseline to week 26 post-quit (t = 2.85, P = 0.004), Abstainers’ weekly alcohol consumption did not change significantly from baseline to week 26 post-quit (t = −1.62, P = 0.11) (see Figure 4).
FIGURE 4.
Adjusted log transformed means for weekly alcohol consumption for relapsers versus abstainers in Break Free. The vertical axis indicates the average log transformed number of drinks per week reported by participants.
Moderation by race and gender
For all three measures of alcohol use in all three datasets, gender was not a significant moderator of time. In CARE, race/ethnicity was not a significant moderator for any of the three measures of alcohol use. Results available from authors on request.
DISCUSSION
The current study examined changes in alcohol use during a smoking quit attempt, including testing for co-action (i.e. that success or failure at quitting smoking will be associated with differential changes in alcohol use). Results are generally consistent with previous research indicating that alcohol consumption decreases during a smoking cessation attempt. In all three studies, decreases in weekly alcohol consumption were present at 3 to 5 weeks post-quit day, and this decrease was maintained through 6 months in two of the three data sets. We found mixed results for binge drinking with decreases in CARE and Break Free, but not PNS. This research also provides some of the first evidence that alcohol-related problems decrease during a smoking cessation attempt as both CARE and Break Free demonstrated this effect. Finally, there was very little evidence for co-action as changes in alcohol use were not limited to those who were abstinent. Abstainers showed a larger decrease than relapsers only for the long-term follow-up of alcohol consumption in Break Free.
Decreases in alcohol consumption occurred for both abstainers and relapsers. In the one analysis that found moderation by smoking abstinence status (Break Free), decreases were larger for abstainers, but were also found for relapsers. These findings could potentially be accounted for by behavioral changes that occur and are maintained during a smoking quit attempt. That is, if smokers make and maintain behavioral changes (e.g. avoiding bars or friends who smoke and drink), those changes may lead to decreases in alcohol consumption, regardless of their success at influencing smoking cessation. Similarly, motivation to make healthy lifestyle changes might reduce alcohol consumption and continue even after a lapse to smoking. It is unclear whether explanations emphasizing the role of smoking abstinence in decreasing alcohol consumption, including smoking acting as a cue to drink or avoiding drinking to reduce cravings for a cigarette [29, 32, 33] can be answered by these findings. Assessing smoking and alcohol use more frequently (e.g. daily, weekly) would provide a more thorough assessment. Nonetheless, when decreases in binge drinking (Break Free) and alcohol-related problems (CARE, Break Free) were found, they occurred equally for both relapsers and abstainers. As with alcohol consumption, behavioral change and motivational explanations may be a better fit for these results than explanations focused on the role of smoking abstinence, although future research is needed to fully investigate this hypothesis.
Results have important clinical implications. The current findings fit with a growing literature suggesting that fear of increased alcohol use during a quit attempt is unwarranted and that smokers who attempt to quit smoking, regardless of success, will at worst experience no change in alcohol use and at best decrease alcohol use [20–24, 26, 27]. These benefits occur with average alcohol consumption, binge drinking and alcohol-related problems. The smoking cessation treatments in the current studies did not explicitly focus on alcohol use, although drinking was discussed if it was an area of concern for the participant. This suggests that decreases in alcohol during a smoking quit attempt can occur with standard smoking cessation treatment (the combination of nicotine replacement therapy and brief smoking cessation counseling) [57]. Additionally, alcohol use may be reduced even further with treatments specifically designed to address both smoking cessation and alcohol risk reduction, at least among smokers who are able to successfully quit [18]. An important caveat is that in all three studies, participants used nicotine patches and received counseling. It is unclear whether these results would generalize to smoking quit attempts that do not involve these treatment components or that entail different treatments.
PNS results were different than the other data sets. The lack of significant results in PNS could be because of a smaller sample size or because the sample consisted of Spanish speaking, predominantly Mexican immigrants to the United States, and change in alcohol use during a cessation attempt could be culturally dependent or influenced by acculturation status. Further research is warranted.
Co-action was defined as a change in alcohol use that differed by abstinence status (abstinent vs smoking). However, measures of smoking abstinence and alcohol use were only measured together at several time points and in a relatively gross fashion. Therefore, these findings could mask co-action that occurs at a more ‘micro’ or ‘episodic’ level. For example, choosing to refrain from smoking at a party might contribute to reduced alcohol consumption, versus choosing to smoke contributing to increase drinking. A more detailed measurement procedure such as ecological momentary assessment could better pinpoint when smoking occurs during a quit attempt and how that influences alcohol use.
Limitations and strengths
Despite using multiple studies with diverse samples, there are several limitations to note. Alcohol use was self-reported, relying on participants to accurately recall their use. The measures of binge drinking in CARE and Break Free did not adjust the definition of binge drinking by participant gender. In addition, participants were not recruited based on their alcohol use, which might lead to underpowered analyses. Missing data were present across all three studies and should be considered on interpretation of the results. It is possible that for some analyses (e.g. co-action) we were underpowered to detect significant effects. It is unclear how well these results would generalize to smokers trying to quit without nicotine replacement and counseling. Future research should explore explanations for decreases in alcohol use during a cessation attempt, which the current studies were not designed to test. Finally, the sample excluded those with alcohol dependence, and recruitment for all studies was conducted in a single city, which could limit generalizability. Strengths include the consideration of several types of alcohol use outcomes, inclusion of measures of alcohol use and smoking abstinence in both the short and long-term, and examination of racially and ethnically diverse samples.
CONCLUSION
Across three unique data sets using diverse samples, little support was found for co-action of smoking abstinence and change in alcohol use during a smoking cessation attempt. Results indicate that decreases in alcohol use during a smoking cessation attempt are not dependent on successfully achieving and maintaining smoking abstinence. These findings have important clinical implications as there was no evidence of a negative impact (and some evidence of a positive impact) of smoking cessation treatment on alcohol use.
Funding information
National Institute on Drug Abuse, Grant/Award Number: R01DA014818; National Cancer Institute, Grant/Award Numbers: R01CA094826, R25TCA57730, U54CA153505, P30CA016672, P30CA042014; National Center on Minority Health and Health Disparities, Grant/Award Numbers: P60MD000503, R00MD010468; American Cancer Society, Grant/Award Number: MRSG-15-018-01-CPPB. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
DECLARATION OF INTERESTS
P.M.C. has served on the scientific advisory board of Pfızer Pharmaceuticals and has conducted educational talks sponsored by Pfızer on smoking cessation for physicians in 2008. No other financial disclosures were reported by the authors of this paper.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.