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An Epidemiologic Analysis of Co-Occurring Alcohol and Tobacco Use and Disorders

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An Epidemiologic Analysis of Co-Occurring Alcohol and Tobacco Use and Disorders An Epidemiologic Analysis of Co-Occurring Alcohol and Tobacco Use and Disorders Findings From the National Epidemiologic Survey on Alcohol and Related Conditions Daniel E. Falk, Ph.D.; Hsiao-ye Yi, Ph.D.; and Susanne Hiller-Sturmhöfel, Ph.D. The 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) sought to determine the prevalence of drinking, smoking, and associated disorders in the general population. This survey, which includes a large representative sample of the adult population of the United States, found that drinking rates were highest among young adults and declined with increasing age. Rates of smoking and co-use of alcohol and tobacco were highest among the youngest respondents and declined thereafter. Similar patterns existed for the presence of alcohol use disorders (AUDs), nicotine dependence, and comorbidity between AUDs and nicotine dependence. Among ethnic/racial groups evaluated, Whites were most likely to drink and Native Americans/Alaskan Natives were most likely to smoke and to have an AUD, nicotine dependence, or comorbid AUD and nicotine dependence. Finally, the rates of tobacco use, daily tobacco use, and nicotine dependence increased with increasing levels of alcohol consumption and the presence of an AUD. These findings have important implications for the development of prevention and intervention approaches. KEY WORDS: Age differences; epidemiology; alcohol and other drug use disorders (AODD); racial differences; tobacco; nicotine; comorbidity; ethnic differences; gender differences umerous studies have demon- and society, it is important to understand the treatment outcome for dependence strated that excessive alcohol the mechanisms contributing to the use on the other substance. For example, Nconsumption and tobacco use and abuse of both substances. Many studies have begun to address the fol­ are independently associated with a studies into these mechanisms have lowing questions: Are alcohol-dependent plethora of health-related, social, and identified brain molecules, such as neu- patients who are also nicotine depen­ economic adverse consequences for the rotransmitters and nicotinic receptors, dent less likely to have successful alco­ consumers of these legal substances as that interact with alcohol and/or nico- holism treatment outcomes than those well as for society at large (Centers for tine and which mediate the effects of Disease Control and Prevention [CDC] these substances on the brain. Similar 2004, 2005a). Some of these detrimen- analyses also have identified mechanisms DANIEL E. FALK, PH.D., is a research tal effects can be exacerbated in people that mediate sensitivity to alcohol and/ analyst and HSIAO-YE YI, PH.D., is a who use and abuse both substances. For or nicotine, as well as the rewarding senior research analyst with the Alcohol example, the risk of certain cancers is properties of the two drugs. (For more Epidemiologic Data System of the greater for people who drink and smoke information on these mechanisms, see National Institute on Alcohol Abuse and than for people who use only one of the articles by Funk and colleagues, Alcoholism (NIAAA), which is operated these substances (National Institute on Davis and de Fiebre, and Grucza and by CSR, Incorporated, Arlington, Virginia. Alcohol Abuse and Alcoholism [NIAAA] Bierut in this issue.) 1998a). To prevent the harmful inter- Another large area of research is con- SUSANNE HILLER-STURMHÖFEL, PH.D., action of alcohol and tobacco use and cerned with how the use of or depen- is senior science editor for Alcohol ameliorate its impact on the individual dence on one of these substances affects Research & Health. 162 Alcohol Research & Health Co-Occurring Alcohol and Tobacco Use Disorders patients who are not nicotine dependent? • DiFranza and Guerrera (1990) is based on a comprehensive definition Should both dependencies be treated at found that 83 percent of alcoholics of tobacco use including all tobacco the same time or consecutively? And are were smokers, compared with 34 modalities, with all prevalence estimates special treatment approaches needed for percent of nonalcoholics. presented by gender, race/ethnicity, and patients who are dependent on both age. In addition, the present study rather than just one substance? This • Bobo and Husten (2000) showed expands upon the work of Anthony research already has yielded valuable that 37 percent of adults who were and Echeagaray-Wagner (2000) by insights. (For more information, see the classified as current drinkers were analyzing how tobacco use and nicotine articles by Foulds and colleagues, Gulliver also current smokers, compared dependence vary with levels of alcohol and colleagues, Ziedonis and colleagues, with 13 percent of abstainers. consumption and types of alcohol use and Kodl and colleagues in this issue.) disorders (AUDs). Although all of these avenues of • Other analyses indicated that smoking research are of the utmost importance, it rates and the number of cigarettes smoked increase with increasing is equally critical to obtain a solid under­ Methods alcohol consumption (e.g., Friedman standing of the scope of the problem. et al. 1991). Thus, it is important to know the rates Data of alcohol and tobacco use and co-use in Although data such as these strongly the general population and whether certain point to an association between drinking The present study is based on data from demographic subgroups are particularly and smoking, the existing studies often the first wave of the NIAAA-sponsored at risk of using both alcohol and tobacco have characteristics that, while making NESARC, which was conducted in or being dependent on both substances. them useful for addressing specific 2001–2002. NESARC is among the Studies of this nature are rare in the research questions, limit their generaliz­ largest nationally representative comor­ literature. In a previous issue of Alcohol ability to the general population. These bidity surveys ever conducted and Research & Health, Anthony and characteristics include the use of treatment includes extensive questions on alcohol Echeagaray-Wagner (2000) presented samples, local community samples, or and tobacco (as well as other substance) an epidemiologic analysis of alcohol and special subpopulation samples rather use and related disorders. The NESARC tobacco use and co-use using national than nationally representative samples. sample includes 43,093 respondents data collected before 1997. This analysis Moreover, most comorbidity studies ages 18 and older, representing the found that the prevalence of co-occurring focused on smoking or cigarette smok­ civilian, noninstitutionalized adult alcohol and tobacco use and disorders ing as the measure of tobacco use (e.g., population of the United States, includ­ was lowest among young adolescents, Dawson 2000; Anthony and Echeagaray- ing residents of all 50 States and the peaked among young adults, and Wagner 2000; Friedman et al. 1991), District of Columbia. Military personnel declined thereafter. The peak rate of ignoring other modalities of tobacco living off base and persons living in alcohol and tobacco co-use among young use (e.g., the use of snuff and chewing noninstitutionalized group-quarter adults ranged from 35 to 45 percent, tobacco). In addition, many of the housing, such as boarding houses, shelters, and dormitories, also were included (Grant and the peak rate of co-dependence was existing studies were based on surveys et al. 2003). The sampling frames for approximately 10 percent. conducted in the 1980s and have used housing units and group-quarter units In addition to determining the diagnostic criteria that are no longer current. Particularly with the preva­ were derived from the Census 2000/ prevalence of co-occurring alcohol and 2001 Supplementary Survey and the tobacco use and disorders in the general lence of tobacco use declining dramati­ cally in the United States in recent Census 2000 Group Quarters Inventory, population and for certain demographic decades (Marks et al. 1997; CDC 2005b), respectively. NESARC oversampled subgroups, it is important to understand epidemiological studies based on current Blacks, Hispanics, and young adults how rates of tobacco use and nicotine national data are needed to provide (ages 18–24) to allow for more reliable dependence vary among people with updated estimates of alcohol and tobacco estimates of these groups. Data were col­ different characteristics of alcohol con­ co-use in the general population. lected via face-to-face, computer-assisted sumption. Over the last 20 years or more, This article addresses these issues interviews in household settings. From accumulating evidence has indeed by updating the findings presented by each household, one adult was selected pointed to a dose-response relationship Anthony and Echeagaray-Wagner for interview. The overall response rate between alcohol and tobacco use: (2000) using data from the 2001–2002 for NESARC was 81 percent. National Epidemiologic Survey on • Dawson (2000) reported that peo­ Alcohol and Related Conditions Measures ple who abuse or are dependent (NESARC). The main objective is to on alcohol are more likely to use present data on the prevalence and Alcohol Measures. All alcohol mea­ tobacco and are heavier users than pattern of alcohol and tobacco use and sures reflect consumption and diagnos­ people who abstain from alcohol. co-use in the United States. This analysis tic status during the past year (i.e., the Vol. 29, No. 3, 2006 163 12 months
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