1 Institute of Epidemiology and Social Medicine, University of Greifswald, Greifswald and 2 Department for Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
(Received 15 May 2003; first review notified 15 June 2003; in revised form 8 July 2003; accepted 31 July 2003)
* Author to whom correspondence should be addressed at: Institute of Epidemiology and Social Medicine, University of Greifswald, Walther-Rathenau-Strasse 48, D-17487 Greifswald, Germany. Tel.: +3 834 867700; Fax: +3 834 867701; E-mail: ujohn{at}uni-greifswald.de; http://www.medizin.uni-greifswald.de
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ABSTRACT |
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INTRODUCTION |
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Common causes may be active both in the relationship between smoking and nicotine dependence, and between smoking and alcohol dependence. A high consumption of one substance may entail a high consumption of the other one. From this, it can be hypothesized that dependence on both substances is probable (cf. Henningfield and Heishman, 1995; Little, 2000
). There may be a third factor which determines the amount of smoking and alcohol drinking and nicotine and alcohol dependence, such as a genetic predisposition, not only to dependence but to a high severity of it (True et al., 1999
; Tyndale, 2003
).
Few population data have been published about the co-occurrence of smoking and nicotine dependence and smoking and alcohol dependence. There is more alcohol consumption among current as well as former smokers than among non-smokers (Carmody et al., 1988). In a population sample, 2% were dependent on both nicotine and alcohol (Kandel et al., 2001
). There were more alcohol-dependent individuals among smokers than among non-smokers [odds ratio (OR) 2.7, confidence interval (CI) 1.84.0, for dependent and OR 2.1, CI 1.43.2, for non-dependent smokers] among young adults (1830 years) in a health maintenance organizational study (Breslau, 1995
). Current daily smokers had a higher rate of alcohol dependence than never, former or occasional smokers (Degenhardt and Hall, 2001
; John et al., 2003b
). In a representative adult population sample in Australia, current smokers had an OR of 3.4 for DSM-IV alcohol misuse or dependence (CI 2.64.4) compared to never smokers after controlling for demographic variables, neuroticism and other drug use. The rate of smokers increases with the severity of alcohol-related harm (ARH) (John et al., 2003b
). Hazardous and harmful drinking were defined as moderate degree of ARH alcohol misuse, and remitted and current alcohol dependence as incremental degrees of ARH, with current alcohol dependence as the highest grade of ARH. Those smoking 30 cigarettes or more per day showed an OR of 14.7 for current alcohol dependence versus no ARH (John et al., 2003b
). Furthermore, alcohol misuse or dependence may increase the probability of nicotine dependence in a longitudinal perspective (Jackson et al., 2000a
).
Overall, there is some evidence for the interrelationship between alcohol dependence and tobacco smoking and nicotine dependence. However, from the representative population samples studied, little has been revealed about the details of this relationship. The severity of alcohol-dependence syndrome criteria, measured by the frequency of single variables of the alcohol-dependence syndrome criteria, according to Edwards and Gross (1976), could provide further information. This approach has become known as a measure of the severity of alcohol dependence (Skinner and Allen, 1982
; Stockwell et al., 1983
; Davidson and Raistrick, 1986
; John et al., 2003a
). The severity of alcohol dependence syndrome criteria provides information beyond the categorical diagnosis of alcohol dependence. It provides ranks of the frequency of symptoms, and it covers severity degrees which are below the threshold for a diagnosis of dependence, thus including information about dependent as well as nondependent individuals. The measurement is based on the alcohol dependence syndrome criteria frequency (ASF) which is a measure of the number of alcohol dependence criteria fulfilled and the frequencies of the occurrence of the single symptoms (Skinner and Allen, 1982
; Stockwell et al., 1983
; Davidson and Raistrick, 1986
; John et al., 2003a
). Questionnaires for the measurement of the ASF have been used in several studies (e.g. Alaja and Seppa, 2003
; Wood et al., 2003
). They are a cost-saving diagnostic approach.
The goal of the present study was to explore (1) whether ASF increases with the number of cigarettes per day, years of daily smoking, the rate of nicotine dependence, the number of dependence symptoms and the degree of nicotine dependence, and (2) how strong these relationships are. It is hypothesized that ASF increases by the amount of tobacco smoked and by the number of nicotine-dependence symptoms. The study is part of a series of data analyses of a population-based investigation of nicotine and alcohol dependence and other psychiatric disorders (Meyer et al., 2001).
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SUBJECTS AND METHODS |
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Assessment
Informed consent was given by all individuals prior to the interview. The ASF was assessed by the Severity Scale of Alcohol dependence (SESA), a 28-item standardized self-administered questionnaire developed to estimate ASF (John et al., 2003a). The SESA was chosen for the following reasons. First, it includes only items needed to assess the alcohol dependence syndrome according to Edwards and Gross (1976)
, which was one basis of the DSM-IV alcohol-dependence criteria (American Psychiatric Association, 1994
; for the English language version see John et al., 2000
). Second, it includes a precise response category format. Third, the SESA was developed and validated by using different clinical samples as well as a population-based sample (John et al., 2003a
). Items from all alcohol-dependence syndrome criteria (Edwards, 1986
) were included in the development of SESA. The item analysis revealed that four criteria are covered by the subscales of SESA: increase of tolerance (DSM-IV criterion 1), extreme increase of tolerance (DSM-IV criterion 1), decrease of tolerance, somatic withdrawal symptoms (DSM-IV criterion 2a), psychological withdrawal symptoms (craving) (DSM-IV criterion 2a), narrowing of drinking repertoire (DSM-IV criteria 3, 5), alcohol consumption to avoid withdrawal symptoms (DSM-IV criterion 2b) (John et al., 2003a
). Three DSM-IV criteria of alcohol dependence are not covered: persistent desire or unsuccessful efforts to cut down or control substance use (criterion 4), important social, occupational, or recreational activities given up or reduced because of substance use (criterion 6), and substance use continued despite knowledge of having a persistent or recurrent problem that is likely to have been caused or exacerbated by the substance (criterion 7). Criteria 4, 6 and 7 proved to be redundant when constructing the subscales using factor analysis and analysis of internal consistency (John et al., 2003a
).
The items of SESA are based on the item pool of three questionnaires estimating the ASF [Alcohol Dependence Scale (ADS), Skinner and Allen, 1982; Severity of Alcohol Dependence Questionnaire (SADQ), Stockwell et al., 1983
; Short Alcohol Dependence Data (SADD), Davidson and Raistrick, 1986
]. SESA uses a five-response category format (daily; once a week or more; once a month or more; less than once a month; never), and for the tolerance items a two-response category format (yes; no). The sum score of SESA included the range 0100. The alcohol-dependence criteria were determined. A wide range of alcohol-related harm was covered by the sample, including current alcohol dependence (6.9%), remitted alcohol dependence (11.4%), alcohol misuse according to DSM-IV (22.4%) and hazardous or harmful alcohol drinking (20 g or more pure alcohol per day in women, 30 g or more in men, but no diagnosis of alcohol misuse or dependence) (8.0%). There were also individuals who did not show any of this alcohol-related harm (51.3%). Administering the SESA to individuals having no dependence criteria was shown to be impractical as a considerable number of them expressed concerns about being stigmatized as an 'alcoholic'.
Smoking and nicotine dependence according to DSM-IV was assessed on grounds of the MCIDI. This included single items for the assessment of the seven dependence criteria as well as eight withdrawal symptoms. Nicotine dependence was measured according to the algorithm provided by the MCIDI for a DSM-IV diagnosis (American Psychiatric Association, 1994). The Fagerström Test for Nicotine Dependence (FTND) (Fagerström et al., 1991
; Heatherton et al., 1991
) was administered to the current smokers among the final sample (n = 340) as part of the interview.
Data analyses
Data were analysed with SPSS 11.0. In order to examine univariate relationships of smoking behaviour and dependence symptoms with smoking status and number of quit attempts, we used chi-squared tests (2) and analysis of variance (anova) and three categories of the SESA sum score: 0 indicated no, 0.018.33 low to medium, and 8.34100.00 a high ASF score. Effect sizes were estimated as Cohen's w for
2 tests. Those less than 0.10 indicated no effect, and between 0.10 and 0.30 a small effect (Cohen, 1988
). For the effect size estimate in the analysis of variance, we used omega-squared (
2) (Fidler and Thompson, 2001
), and assumed values up to 0.01 as a small, and values up to 0.06 as a medium effect size (analogous to Cohen's d ) (Cohen, 1988
). For multivariate relationships, we used general linear regression model techniques with the sum score of the SESA as the dependent variable (Rawlings et al., 1998
). Because the FTND was included, only current smokers were considered in this model.
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RESULTS |
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The multivariate analysis showed several relationships between the ASF and smoking-related items and ASF and nicotine dependence variables. The general linear regression model applied (R2 = 0.17) revealed number of years of daily smoking plus the age at onset of smoking, the number of attempts to reduce or quit smoking, the number of nicotine dependence symptoms as well as the FTND sum score as explaining variables for the sum score of the ASF (Table 2). The largest contribution was provided by the FTND score.
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DISCUSSION |
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The data support that smoking onset at a young age is particularly harmful. Those individuals who started smoking at the age of 15 or younger were more likely to be in the high ASF group than individuals with an older onset of smoking age. Those who start smoking early in life might be a subgroup prone to becoming co-dependent (cf. Little, 2000). This subgroup might consist of individuals who are vulnerable to severe dependence, and prevention methods practiced so far among youth might be inappropriate for this subpopulation. Early onset of smoking probably aggregates a large part of tobacco- and alcohol-attributable diseases. Although the number of quit attempts is not linearly related to the ASF in the univariate analysis, there are smokers with more than 10 quit attempts of whom almost half belong to the high ASF group. This might indicate that severe alcohol dependents try to quit smoking often but do not succeed, and more intense interventions might be appropriate.
Among the currently DSM-IV nicotine-dependent smokers, there are almost twice as many in the high ASF group than among the non-dependent smokers, and the number of nicotine-dependence symptoms increases with increasing ASF. This relationship is plausible because the ASF and the DSM nicotine-dependence criteria have a common historical background: the dependence syndrome (Edwards, 1986). However, the FTND, which may be seen as an estimate of the urge to smoke and of withdrawal, shows a relationship with the ASF also, and the effect size seems to be somewhat larger than that of the number of DSM criteria. The DSM criteria and the FTND may mutually contribute to finding details of nicotine- and alcohol-dependence comorbidity. In all, the data support the findings which show comorbidity between nicotine and alcohol dependence (Marks et al., 1997
; Daeppen et al., 2000
). Extending results from a population study limited to young adults (Breslau, 1995
), our study covers a broader age range. Beyond that, the data show that there are linear relationships with the ASF as well.
The general linear regression model reveals five core variables that explain the variance of the ASF. Lifetime smoking is expressed by the number of years of daily cigarette use; a striking finding is that in addition to these variables, the age at onset of smoking remains within the model. Two of the five explaining variables indicate the number of dependence criteria, and the DSM and the FTND add specific information to the overall picture of dependence. Thus, it is appropriate to combine both approaches when diagnosing nicotine dependence when explaining the ASF. Overall, lifetime tobacco smoking, number of quit attempts and a comprehensive measure of nicotine dependence, contribute to the co-occurrence of smoking and a high frequency of alcohol-dependence symptoms. The hypothesis is therefore supported by the data.
As to a causal relationship, the data show that there may be vulnerability to severe dependence on both substances (True et al., 1999; Tyndale, 2003
), and starting smoking at age 15 or younger might be a response to that vulnerability. Or it might be that there is a predisposition to severe dependence, and the interaction between the use of the two substances might reinforce their use. Longitudinal prospective research with children before they start smoking and their families may help to disentangle familial and genetic factors of the severity of comorbid nicotine and alcohol dependence.
The ASF data can be collected in an easy and cost-saving way. The data support the use of self-statement measures when the alcohol-dependence syndrome is a possibility. In routine care, the FTND and a questionnaire measuring the ASF may be administered easily, and thus information about comorbidity can be obtained. Intervention may be differentiated by such diagnostic information, and intervention outcome may take into account the interactions of smoking and drinking more precisely. The data show that two dimensions can be distinguished: the frequency of criteria or symptoms and the substance. Severity of disturbance may be expressed as being dependent on nicotine, alcohol or both, to a medium or high degree. This differentiation enables the tailoring of interventions to the needs of subpopulations with different kinds and degrees of disturbance. The ASF might help to identify subpopulations of smokers and those with harmful levels of alcohol consumption and to provide grounds for efforts for prevention and treatment tailored to the needs of co-dependents.
The following limitations must be taken into account. First, the data are cross-sectional and no causal relationship can be determined. The data show a doseresponse relationship; however, the data do not tell us what is the agent and what is the response. Second, the study has been conducted in a nation with particularly low prevention efforts and high tobacco and alcohol consumption (cf. John and Hanke, 2002). In countries with large prevention efforts, more quitters are to be expected, and the remaining smokers may include a higher rate of dependents than our sample. Third, the sample is representative only for a specific area in Germany. However, our sample does not differ in distribution of age and sex from that of the national population aged 2064 years. Fourth, the group of smokers who provided information about the ASF was heterogeneous with respect to alcohol-related harm. Included were individuals with alcohol dependence, alcohol misuse or hazardous or harmful drinking, but also included individuals with none of these disorders. More homogeneous samples may show stronger relationships between nicotine dependence and the ASF. Fifth, all information has been gathered from self-statements and no biochemical verification was made. There may have been underreporting of dependence symptoms, although other evidence suggests that in population-based studies no risk of denial of smoking exists which would significantly change the results (Vartiainen et al., 2002
). Sixth, the FTND has been assessed in current smokers only.
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CONCLUSIONS |
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Acknowledgements |
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