A prospective study of the effects of cigarette smoking and alcohol abuse on mortality

Pilot randomized controlled trial of mindfulness-based relapse prevention vs cognitive behavioral therapy for smoking and alcohol use

BACKGROUND

The combined use of cigarettes and alcohol is associated with a synergistic increase in the risk of morbidity and mortality. Continued alcohol use during a smoking quit attempt is a considerable risk factor for smoking relapse. As such, there is a need for interventions that address both behaviors concurrently. Mindfulness-based interventions hold much promise for simultaneously addressing tobacco and alcohol use.

METHOD

This pilot study evaluated the feasibility and acceptability of a mindfulness-based intervention using a two-arm randomized controlled trial of Mindfulness-Based Relapse Prevention for Smoking and Alcohol (MBRP-SA) vs Cognitive Behavioral Therapy (CBT). Interventions were delivered via telehealth in a group setting; all participants received a 6-week supply of the nicotine patch. Participants (N = 69) were adults who smoked cigarettes who reported binge drinking and were motivated to both quit smoking and change their alcohol use. Primary outcomes were feasibility and acceptability of MBRP-SA compared to CBT. Changes in tobacco and alcohol use are also presented.

RESULTS

Participants in MBRP-SA and CBT indicated that the treatments were highly acceptable, meeting a priori benchmarks. Feasibility was mixed with some outcomes meeting benchmarks (e.g., recruitment) and others falling below (e.g., retention). Participants in both conditions demonstrated significant reductions in tobacco and alcohol use at the end of treatment.

CONCLUSIONS

In sum, MBRP-SA had comparable outcomes to CBT on all metrics measured. Future research should evaluate the efficacy of MBRP-SA on smoking abstinence and drinking reductions in a large-scale, fully powered trial. This study was registered on clinicaltrials.gov (NCT03734666).

Alcohol Recidivism Following Transjugular Intrahepatic Portosystemic Shunt Placement: Frequency and Predictive Factors

PURPOSE

To determine the frequency and predictive factors for alcohol recidivism following transjugular intrahepatic portosystemic shunts (TIPS) placed in patients with alcoholic cirrhosis.

METHODS

One hundred ninety-nine patients who had a TIPS placed at a single institution for different indications in the setting of alcoholic cirrhosis were reviewed. Length of sobriety prior to TIPS placement and maintained sobriety at 1, 3 and 6-12 months after TIPS placement were recorded. Smoking history, substance abuse and psychiatric comorbidities were also recorded as was ascitic response to TIPS at 1, 3 and 6-12 months.

RESULTS

At 1 month 11/199 (5.5%) patients had experienced a relapse while, 20/199 (10.1%) had at 3 months, and 44/199 (22.1%) had at 12 months. There was no difference in ascitic response in those who did and did not relapse at 1 month (p = 0.57), 3 months (p = 1.00) or 1 year (p = 0.44). The mean time of sobriety at the time of TIPS placement for those who relapsed by 12 months was significantly less than those who did not relapse (5.11 (1.10-7.90) months vs 18.32 (8.63-48.12) months, p < 0.001). Concurrent psychiatric comorbidity (p < 0.001), substance abuse (p < 0.001), age less than 40 (p = 0.004) and smoking history at the time of procedure (p < 0.001) were also associated with alcohol relapse.

CONCLUSION

Recidivism is a frequent issue for patients following TIPS placement; those who have concurrent psychiatric comorbidity, substance abuse, smoking history are younger than 40 and shorter sobriety duration prior to TIPS may be at increased risk.

Development of a mindfulness-based treatment for smoking cessation and the modification of alcohol use: A protocol for a randomized controlled trial and pilot study findings

The combined use of cigarettes and alcohol is associated with an increased risk of morbidity and mortality. Yet, efficacious interventions that address both behaviors concurrently are lacking. Smoking cessation and alcohol modification not only garner health benefits, but there is also value in addressing alcohol use in the context of smoking cessation to reduce the risk for smoking relapse. In this paper we describe the development of mindfulness-based relapse prevention for smoking cessation and alcohol modification (MBRP-SA) and pilot study findings (Phase 1). Next, details regarding the methods and design of an ongoing, randomized controlled trial, Project RISE (Phase 2), are described. MBRP-SA is a group-based intervention that consists of eight weekly treatment sessions. Results from the Phase 1 pilot study (N = 21 enrolled) indicated that participants planned to use the skills learned in their everyday activities and to address their smoking and alcohol goals. Based on the progression of Phase 1 cohorts, modifications were made to the inclusion/exclusion criteria and recruitment methods that will be implemented in Phase 2. Phase 2 will assess the feasibility and acceptability of MBRP-SA, delivered via live online groups, as a primary treatment option for smoking cessation and alcohol use modification.

Socio-economic differences in all-cause mortality in people with alcohol use disorder: a prospective cohort study

BACKGROUND AND AIMS

While alcohol-attributable mortality rates are higher in low socio-economic status (SES) groups, less is known about SES differences in all-cause mortality in alcohol use disorder (AUD). The aim of this study was to explore whether there are SES differences in people with AUD, regarding (i) treatment admission, (ii) all-cause mortality risk and (iii) relative mortality risk.

DESIGN AND SETTING

A prospective cohort study in Norway, follow-up period from 2009-10 to 2013. Data on SES and mortality were obtained through linkages to national registries, using national unique ID numbers.

PARTICIPANTS

AUD patients (age 20+) admitted to treatment in 2009-10 (n = 11 726) and age and gender frequency-matched controls from the general population (n = 12 055).

MEASUREMENTS

The SES indicator was education level (low, intermediate and high). Mortality was calculated as deaths per 1000 person-years during the 4-year observation period.

FINDINGS

Admission to AUD treatment was elevated in the low compared with the high SES categories (OR = 3.31, 95% CI = 3.09, 3.55). Among AUD patients, mortality risk was elevated in the low SES category (HR = 1.23, 95% CI = 1.04, 1.45). Relative mortality risk from AUD was significantly higher in the high SES (HR = 8.65, 95% CI = 6.16, 12.14) compared with the low SES categories (HR = 3.29, 95% CI = 2.61, 4.15).

CONCLUSION

Admission to treatment for alcohol use disorders in Norway appears to decrease with increasing socio-economic status, and relative mortality risk from alcohol use disorder appears to increase with increasing socio-economic status.

Smoking characteristics and alcohol use among women in treatment for alcohol use disorder

BACKGROUND

Understanding the association between smoking and alcohol use among women may help inform the delivery of targeted interventions to address both of these health behaviors.

METHODS

This study analyzed data from N = 138 women enrolled in a randomized clinical trial comparing female-specific individual versus group cognitive-behavior therapy for alcohol use disorder (AUD). We assessed cigarette use patterns, participants' interest in quitting smoking and motivation to quit smoking during treatment for AUD, and examined the relationship between smoking and alcohol use before and during alcohol treatment.

RESULTS

Over a third of the sample reported smoking cigarettes at baseline (N = 47, 34.1%), with the majority of smokers reporting daily cigarette use. At baseline, those who smoked reported a high interest in quitting smoking M = 7.8 out of 10 (SD = 2.7), although most believed they should quit smoking only after achieving some success in quitting drinking (50.0%). However, participants who smoked cigarettes (compared to non-smokers) reported more alcohol abuse and dependence symptoms (p = .001), lower rates of completing the alcohol treatment (p = .03), attended significantly fewer treatment sessions (p = .008), and consumed significantly more drinks per day on average both at baseline (p = .002) and during the treatment period (p = .04).

CONCLUSIONS

Findings suggest that women with AUD who also smoke cigarettes have greater difficulty engaging in or responding to treatment for their alcohol use. However, these participants reported high interest in quitting smoking but low perceived readiness during AUD treatment, suggesting that motivational interventions should be considered that could take advantage of the opportunity to treat women for both of these co-occurring behaviors while in treatment.

Current tobacco use, nicotine dependence, and transitions across stages of alcohol involvement: A latent transition analysis approach

OBJECTIVES

This study aims to examine the (a) probability of transition between stages of alcohol involvement and (b) influence of tobacco use and nicotine dependence on transitions.

METHODS

Data came from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Latent transition analysis estimated the probability of transitioning between stages of alcohol involvement across waves and the impact of tobacco use and nicotine dependence at Wave 1 on transitions.

RESULTS

Males reporting current tobacco use but no dependence at Wave 1 were more likely to progress from No Problems to Moderate Problems (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI] [1.44, 2.22]) and from No Problems to Severe Problems (aOR = 2.44; 95% CI [1.25, 4.77]) than nontobacco users. Females reporting current tobacco use but no dependence were more likely to progress from No Problems to Moderate Problems (aOR = 2.00; 95% CI [1.37, 2.94]) and from No Problems to Severe Problems (aOR = 2.87; 95% CI [1.34, 6.13]). Females reporting current tobacco use and dependence were more likely than females not using tobacco to transition from Moderate to No Problems (aOR = 2.10; 95% CI [1.04, 4.22]).

CONCLUSIONS

Results suggest that tobacco use is a preceding correlate of progression in alcohol involvement among males and females. Among females, tobacco use and nicotine dependence are also related to alcohol involvement recovery.

Paradox and privilege: A 55-year follow-up of the mortality of Yale College graduates

Objective

Two hypotheses were tested: 1. People from privileged backgrounds had better survival than those from less privileged backgrounds. 2. The advantages of privilege were vitiated by fraternity membership.

Methods

A 55-year retrospective cohort study of survival since 1960 of 945 graduates of Yale College followed to 2015.

Results

The survival of graduates of private secondary schools (the privileged group) did not differ from that of public school graduates. However, graduates of private secondary schools who had not joined a fraternity in college had significantly better survival than private school graduates who had joined fraternities and than public school graduates, whether fraternity members or not.

Conclusions

The benefits of a privileged background in respect of survival were undermined by fraternity membership. It is suggested that both self-selection and substance mis-use may have contributed to the survival difference.

•

Membership in college fraternities is associated with an increased risk of death.

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Privileged background is not associated with reduced risk of death.

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Privileged background and not being in a fraternity had the lowest mortality.

•

The advantage of privilege may be undermined by fraternity membership.

Exploring the Utility of Web-Based Social Media Advertising to Recruit Adult Heavy-Drinking Smokers for Treatment

Background

Identifying novel ways to recruit smokers for treatment studies is important. In particular, certain subgroups of adult smokers, such as heavy-drinking smokers, are at increased risk for serious medical problems and are less likely to try quitting smoking, so drawing this hard-to-reach population into treatment is important for improving health outcomes.

Objective

This study examined the utility of Facebook advertisements to recruit smokers and heavy-drinking smokers for treatment research and evaluated smoking and alcohol use and current treatment goals among those who responded to the Web-based survey.

Methods

Using Facebook’s advertising program, 3 separate advertisements ran for 2 months targeting smokers who were thinking about quitting. Advertisements were shown to adult (at least 18 years of age), English-speaking Facebook users in the greater New Haven, Connecticut, area. Participants were invited to complete a Web-based survey to determine initial eligibility for a smoking cessation research study.

Results

Advertisements generated 1781 clicks and 272 valid, completed surveys in 2 months, with one advertisement generating the most interest. Facebook advertising was highly cost-effective, averaging $0.27 per click, $1.76 per completed survey, and $4.37 per participant meeting initial screening eligibility. On average, those who completed the Web-based survey were 36.8 (SD 10.4) years old, and 65.8% (179/272) were female. Advertisements were successful in reaching smokers; all respondents reported daily smoking (mean 16.2 [SD 7.0] cigarettes per day). The majority of smokers (254/272, 93.4%) were interested in changing their smoking behavior immediately. Many smokers (161/272, 59.2%) also reported heavy alcohol consumption at least once a month. Among smokers interested in reducing their alcohol use, more were heavy drinkers (45/56, 80.4%) compared to non-heavy drinkers (11/56, 19.6%; χ²[_1,N=272]=13.0, P<.001). Of those who met initial screening eligibility from the Web-based survey, 12.7% (14/110) attended an in-person follow-up appointment.

Conclusions

Social media advertisements designed to target smokers were cost-effective and successful for reaching adult smokers interested in treatment. Additionally, recruiting for smokers reached those who also drink alcohol heavily, many of whom were interested in changing this behavior as well. However, additional social media strategies may be needed to engage individuals into treatment after completion of Web-based screening surveys.

Effectiveness of Varenicline in Psychiatric Patients with Co-Morbid Polysubstance Dependence

Introduction: Individuals with substance use disorders (SUDs) and mental health disorders (MHDs) have greater prevalence of smoking and suffer greater tobacco-related morbidity and mortality. Varenicline is the latest FDA-approved smoking-cessation agent and few studies have investigated the use of varenicline in this difficult-to-treat population.

Aims: This study examines the smoking cessation outcomes and tolerability of varenicline when used to help quit smoking in 16 patients enroled in both psychiatric and substance abuse programme.

Methods: A retrospective chart review was conducted on 16 patient charts. Patient demographics, psychiatric disorder diagnoses, substance use history, dosing, side effects, number of cigarettes used pre/post varenicline use and the number of complete smoking cessation outcomes were tabulated.

Results: After varenicline intervention, 25% of those who completed treatment completely quit smoking. Thirty-one per cent were able to substantially cut back the amount that they smoked to one cigarette per day. The average reduction in cigarettes was 16 per day (64%), and all but one patient tolerated varenicline.

Conclusions: The authors observed reasonable clinical benefit when varenicline was used to help quit smoking in patients with comorbid SUDs and MHDs. Better-controlled future studies with larger sample sizes will help further determine clinical utility of varenicline in this difficult-to-treat nicotine-dependent population.

Heavy-Drinking Smokers' Treatment Needs and Preferences: A Mixed-Methods Study

The purpose of this mixed methods study was to describe the smoking and psychological characteristics of heavy-drinking smokers, their perceptions of smoking and drinking, and their smoking and alcohol treatment preferences to inform an integrated smoking and alcohol intervention. Heavy-drinking smokers (N=26) completed standardized surveys and participated in semi-structured focus group interviews. Participants reported a strong association between their smoking and drinking. Participants were more motivated to quit smoking than to reduce their drinking but perceived greater barriers to smoking cessation. Stress/negative affect was closely linked with both behaviors. They expressed overall enthusiasm for a smoking and alcohol intervention but had specific format and content preferences. Half preferred an integrated treatment format whereas others preferred a sequential treatment model. The most preferred content included personalized health feedback and a way to monitor health gains after behavior changes.

The effects of prenatal exposure to alcohol and environmental tobacco smoke on risk for ADHD: a large population-based study

Attention deficit hyperactivity disorder (ADHD) is caused by the interaction of genetic and environmental factors. The objective of this study was to examine the effects of prenatal exposure to alcohol and environmental tobacco smoke (ETS). Among the 30,552 parents who responded to a survey, the answers of 19,940 who replied to questions on prenatal exposure to ETS, alcohol consumption, and completed the DuPaul Rating Scale were analyzed. Results revealed that risk of ADHD significantly increased as a result of exposure to alcohol by 1.55 times (95% CI 1.33-1.82), maternal smoking during pregnancy by 2.64 times (95% CI 1.45-4.80), and paternal smoking during pregnancy by 1.17 times (95% CI 1.98-1.39). When the subjects whose mothers did not smoke during pregnancy were divided into 4 groups, the prevalence was 1.16 times higher (95% CI 1.02-1.33) in the group exposed to ETS but not alcohol, 1.19 times higher (95% CI 0.91-1.57) in the group exposed to alcohol but not ETS, and 1.58 times higher (95% CI 1.31-1.91) in the group exposed to ETS and alcohol. The differences between the groups were statistically significantly (P<0.0001). This result shows that simultaneous exposure to ETS and alcohol during pregnancy increases the risk of ADHD.

Antecedents of intact cognition and dementia at age 90 years: a prospective study

OBJECTIVES

This study aimed to examine the possible antecedents of both dementia and sustained intact cognition at age 90 years among men who underwent a prospective, multidisciplinary assessment from ages 19 to 90 years, with little attrition.

METHODS

We conducted a prospective 20-year reassessment of 196 (out of 268) former Harvard college sophomores who survived until age 70 years. Since 1939, the study gathered measurements of childhood environment, dominant personality traits, objective mental and physical health over time, smoking in pack-years, alcohol abuse, and depression. Questionnaires were obtained every 2 years and physical exams every 5 years. Cognitive status was assessed at ages 80, 85, and 90 years.

RESULTS

Despite addressing a wide variety of health, behavioral, and social factors over the lifespan, we observed few predictors with strong association with either intact cognition at age 90 years (n = 40) or dementia (n = 44). Univariate analysis revealed seven suggestive predictors of intact cognition at age 90 years or of dementia: warm childhood relationship with mother, exercise at age 60 years, high maternal education, young age of mother at subject's birth, low body mass index, good physical health at 60 years, and late retirement. Only the first three variables, warm childhood relationship with mother, exercise at age 60 years, and high maternal education, remained significant with logistic regression.

CONCLUSIONS

In this prospective study of long-lived, highly educated men, several well-known putative predictors of Alzheimer's disease did not distinguish those who over the next 20 years developed dementia from those with unimpaired cognition until age 90 years.

Gender differences in association with substance use diagnoses and smoking

Alcohol and drug use disorders are highly comorbid with tobacco use. Given the substantial health risks associated with concurrent substance use and smoking, there is a clinical need to identify factors that confer heightened risk for their cause. This investigation examined gender-specific associations between smoking behaviors with current alcohol and drug use diagnoses. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (N = 42,565). Relationships between smoking status and DSM-IV current alcohol and drug use diagnoses by gender were assessed in terms of odds ratios using regressions. The presence of current alcohol or drug diagnoses increased the odds of being a daily, occasional, or former smoker, and gender was found to moderate these associations. Overall, women with a current alcohol use disorder had greater odds of being a daily or occasional smoker compared with men (odds ratio [OR], 3.52 versus 2.93; 5.22 versus 3.56). Women with a drug use diagnosis had greater odds of being a daily smoker compared with men (OR, 6.54 versus 4.63) and similar odds of being an occasional smoker (OR, 4.48 versus 4.51). The results of this study highlight gender-specific patterns of comorbidity, which may contribute to more focused primary and secondary prevention efforts.

Smoke-free policies in drinking venues predict transitions in alcohol use disorders in a longitudinal U.S. sample

BACKGROUND

Smoke-free legislation prohibiting smoking in indoor public venues, including bars and restaurants, is an effective means of reducing tobacco use and tobacco-related disease. Given the high comorbidity between heavy drinking and smoking, it is possible that the public health benefits of smoke-free policies extend to drinking behaviors. However, no prior study has examined whether tobacco legislation impacts the likelihood of alcohol use disorders (AUDs) over time. The current study addresses this gap in the literature using a large, prospective U.S. sample.

METHOD

Using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we utilized logistic regression to examine whether the implementation of state-wide smoke-free legislation in bars and restaurants between Waves I (2001-2002) and II (2004-2005) predicted changes in DSM-IV AUD status (remission, onset, recurrence) in current drinkers at Wave I (n=19,763) and participants who drank in public ≥once per month (n=5913).

RESULTS

Individuals in states that implemented smoke-free legislation in drinking venues had a higher likelihood of AUD remission compared to participants in states without such legislation. Among public drinkers, smoke-free legislation was associated with a greater likelihood of AUD remission and a lower likelihood of AUD onset. These findings were especially pronounced among smokers, men, and younger age groups.

DISCUSSION

These results demonstrated the protective effects of smoke-free bar and restaurant policies on the likelihood of AUDs; furthermore, these findings call attention to an innovative legislative approach to decrease the morbidity and mortality associated with AUDs.

Longitudinal associations between smoking cessation medications and alcohol consumption among smokers in the International Tobacco Control Four Country survey

BACKGROUND

Available evidence suggests that quitting smoking does not alter alcohol consumption. However, smoking cessation medications may have a direct impact on alcohol consumption independent of any effects on smoking cessation. Using an international longitudinal epidemiological sample of smokers, we evaluated whether smoking cessation medications altered alcohol consumption independent of quitting smoking.

METHODS

Longitudinal data were analyzed from the International Tobacco Control Four Country (ITC-4) Survey between 2007 and 2008, a telephone survey of nationally representative samples of smokers from the United Kingdom, Australia, Canada, and the United States (n = 4,995). Quantity and frequency of alcohol consumption, use of smoking cessation medications (varenicline, nicotine replacement [NRT], and no medications), and smoking behavior were assessed across 2 yearly waves. Controlling for baseline drinking and changes in smoking status, we evaluated whether smoking cessation medications were associated with reduced alcohol consumption.

RESULTS

Varenicline was associated with a reduced likelihood of any drinking compared with nicotine replacement (OR = 0.56; 95% CI = 0.34 to 0.94), and consuming alcohol once a month or more compared to nicotine replacement (OR = 0.43; 95% CI = 0.27 to 0.69) or no medication (OR = 0.63; 95% CI = 0.41 to 0.99). Nicotine replacement was associated with an increased likelihood of consuming alcohol once a month or more compared to no medication (OR = 1.14; 95% CI = 1.03 to 1.25). Smoking cessation medications were not associated with more frequent drinking (once a week or more) or typical quantity consumed per episode. Medication effects on drinking frequency were independent of smoking cessation.

CONCLUSIONS

This epidemiological investigation demonstrated that varenicline was associated with a reduced frequency of alcohol consumption. Continued work should clarify under what conditions nicotine replacement therapies may increase or decrease patterns of alcohol consumption.

In the heat of the moment: alcohol consumption and smoking lapse and relapse among adolescents who have quit smoking

BACKGROUND

The present study tested the co-occurrence of alcohol use and the first lapse and relapse into smoking among daily smoking adolescents who quit smoking.

METHODS

In this ecological momentary assessment study, participants completed web-based questionnaires three times a day during one week prior to and three weeks after a quit attempt in their own natural environments. Participants were 134 daily smoking adolescents in the aged 15-19. Hierarchical linear modeling was applied to test whether alcohol use was related to the first lapse and relapse. Lapse was defined as the first incidence of smoking after achieving 24-h abstinence, relapse was defined as smoking at least five cigarettes on three consecutive days.

RESULTS

The first lapse was strongly associated with alcohol use. Individual characteristics (age, sex, and baseline smoking status) did not predict the first lapse nor did they moderate the association between alcohol use and the first lapse. Progression from lapse to relapse did not seem to be associated with alcohol consumption, although this association appeared to be moderated by baseline smoking status. More specifically, alcohol use only posed a significant risk factor for relapse among those who smoked less frequently before the start of the study than others who relapsed. Intermittent smoking between the first lapse and relapse (or end of data) was strongly associated with alcohol use.

CONCLUSIONS

Adolescent drinking during smoking cessation seems to be associated with the first lapse into smoking after quitting and subsequent intermittent smoking and should be targeted in adolescent smoking cessation interventions.

Smoke-free bar policies and smokers' alcohol consumption: findings from the International Tobacco Control Four Country Survey

BACKGROUND

Cigarette smoking and alcohol consumption are positively correlated, and the concurrent use of tobacco and alcohol exacerbates the health risks associated with the singular use of either product. Indoor smoke-free policies have been effective in reducing smoking, but little is known about any impact of these policies on drinking behavior. The purpose of this study was to evaluate the potential association between the implementation of smoke-free bar policies and smokers' alcohol consumption.

METHODS

A prospective, multi-country cohort survey design was utilized. Participants were nationally representative samples of smokers from the United Kingdom, Australia, Canada, and the United States, who were interviewed as part of the International Tobacco Control Four Country Survey (ITC-4) in 2005, 2007, or 2008 (N=11,914). Changes in the frequency and amount of alcohol consumption were assessed as functions of change in the presence of smoke-free bar policies over time.

RESULTS

Overall, changes in alcohol consumption were statistically indistinguishable between those whose bars became smoke-free and those whose bars continued to allow smoking. However, implementation of smoke-free policies was associated with small reductions in the amount of alcohol typically consumed by those who were classified as hazardous drinkers, along with small reductions in the frequency of alcohol consumption among heavy smokers.

CONCLUSIONS

Smoking bans in public places, which protect millions of non-smokers from the harmful effects of second-hand smoke, do not appear to be associated with sizable reductions in smokers' alcohol consumption in general, but may be associated with small consumption reductions among subgroups.

Health-related quality of life differences between African Americans and non-Hispanic whites with head and neck cancer

BACKGROUND

Cancers of the head and neck are associated with detriments in health-related quality of life (HRQOL); however, little is known about different experiences between African Americans and non-Hispanic whites.

METHODS

HRQOL was measured by the Functional Assessment of Cancer Therapy - Head and Neck (FACT-H&N) approximately 5 months postdiagnosis among 222 patients with cancer from North Carolina. Higher scores represent better HRQOL. Regression models included sociodemographic characteristics and clinical factors.

RESULTS

African Americans reported higher physical well-being than whites (adjusted means, 23.1 vs 20.9). African Americans with incomes <$20,000 reported higher emotional well-being (21.4) and fewer head and neck symptoms (22.0). Non-Hispanic whites making <$20,000 reported the poorest emotional well-being (17.3), whereas African Americans making >$20,000 reported the most head and neck symptoms (18.7).

CONCLUSIONS

Further investigation is needed to explore variation in HRQOL experiences among different race and socioeconomic groups that may inform resource allocation to improve cancer care.

Gender differences in drinking patterns and alcohol-related problems in a community sample in São Paulo, Brazil

OBJECTIVE

To investigate drinking patterns and gender differences in alcohol-related problems in a Brazilian population, with an emphasis on the frequency of heavy drinking.

METHODS

A cross-sectional study was conducted with a probability adult household sample (n = 1,464) in the city of São Paulo, Brazil. Alcohol intake and ICD-10 psychopathology diagnoses were assessed with the Composite International Diagnostic Interview 1.1. The analyses focused on the prevalence and determinants of 12-month non-heavy drinking, heavy episodic drinking (4-5 drinks per occasion), and heavy and frequent drinking (heavy drinking at least 3 times/week), as well as associated alcohol-related problems according to drinking patterns and gender.

RESULTS

Nearly 22% (32.4% women, 8.7% men) of the subjects were lifetime abstainers, 60.3% were non-heavy drinkers, and 17.5% reported heavy drinking in a 12-month period (26.3% men, 10.9% women). Subjects with the highest frequency of heavy drinking reported the most problems. Among subjects who did not engage in heavy drinking, men reported more problems than did women. A gender convergence in the amount of problems was observed when considering heavy drinking patterns. Heavy and frequent drinkers were twice as likely as abstainers to present lifetime depressive disorders. Lifetime nicotine dependence was associated with all drinking patterns. Heavy and frequent drinking was not restricted to young ages.

CONCLUSIONS

Heavy and frequent episodic drinking was strongly associated with problems in a community sample from the largest city in Latin America. Prevention policies should target this drinking pattern, independent of age or gender. These findings warrant continued research on risky drinking behavior, particularly among persistent heavy drinkers at the non-dependent level.

A preliminary investigation of varenicline for heavy drinking smokers

RATIONALE

Varenicline, an approved smoking cessation pharmacotherapy, also shows promise as a potential treatment for alcohol dependence. However, varenicline has not been tested in heavy drinkers, and it remains to be determined whether varenicline could reduce alcohol craving and consumption in smokers who are trying to quit smoking.

OBJECTIVES

We conducted a preliminary study to examine the effect of varenicline on drinking behavior and the effects of extended varenicline pretreatment on smoking.

METHODS

Thirty heavy drinking smokers received smoking cessation counseling and were randomly assigned to receive either an extended 4-week pretreatment with varenicline 2 mg daily or the usual 1-week pretreatment. Those in the extended pretreatment group received active medication for 8 weeks (i.e., 4 weeks of active pre-treatment followed by 4 weeks of active treatment), and participants in the usual pretreatment group received active medication after a placebo lead in (i.e., 3 weeks of placebo followed by active medication for 5 weeks).

RESULTS

Participants who received varenicline during the first 3 weeks reported significantly greater reductions in alcohol craving and numerically fewer heavy drinking days compared to those who received placebo, and these differences persisted during the open-label phase. Extended pretreatment was associated with numerically greater reductions in cigarette smoking over the entire study period. There were no differences, however, in smoking abstinence rates following the smoking quit date between the two groups.

CONCLUSIONS

Findings from this preliminary study suggest that varenicline may be a promising strategy for concurrently reducing heavy drinking and promoting smoking changes in heavy drinkers.

Longitudinal evaluation of smoke-free Scotland on pub and home drinking behavior: findings from the International Tobacco Control Policy Evaluation Project

INTRODUCTION

On 26 March 2006, Scotland implemented a smoke-free policy prohibiting smoking in indoor public venues, including bars and pubs. Drinking and smoking are highly associated behaviors, so we evaluated whether the regulations would decrease drinking behavior among smokers in public venues. We further assessed whether this effect would be more pronounced in heavier drinkers and whether decreases in drinking behavior in pubs would be offset by increased drinking in the home.

METHODS

Participants (N = 1,059) were adult smokers and nonsmokers from Scotland and from the rest of the United Kingdom, which did not have comprehensive smoke-free policies during the study period. Data were collected using a random-digit-dialed telephone survey from February to March 2006, just prior to the policy implementation in Scotland. Follow-up surveys were conducted in March 2007. Using baseline data, we categorized participants as abstainers, moderate drinkers, or heavy drinkers.

RESULTS

Overall, results demonstrated that drinking behavior did not change significantly in Scotland compared with the rest of the United Kingdom following implementation of the smoke-free policy in Scotland. However, planned comparisons examining mean changes in drinks consumed in pubs or bars following the legislation demonstrated that the smoke-free legislation was associated with reduced drinking behavior in pubs and bars among moderate- and heavy-drinking smokers in Scotland. These moderate- and heavy-drinking Scottish smokers also reduced their pub attendance following policy implementation.

DISCUSSION

The smoke-free Scottish law did not increase drinking in the home. These findings suggest that smoke-free policies may have additional public health benefits for those at greater risk for alcohol-related health problems.

Effect of transdermal nicotine replacement on alcohol responses and alcohol self-administration

RATIONALE

Nicotine replacement is commonly used to treat tobacco use in heavy-drinking smokers. However, few studies have examined the effect of nicotine replacement on subjective and physiological responses to alcohol and alcohol drinking behavior.

OBJECTIVE

The primary aim of this within-subject, double-blind study was to examine whether transdermal nicotine replacement (0 mg vs 21 mg/day) altered response to a low-dose priming drink and subsequent ad libitum drinking behavior.

MATERIALS AND METHODS

Subjects (n=19) were non-treatment-seeking, non-dependent heavy drinkers who were daily smokers. Six hours after transdermal patch application, subjective and physiological responses to a priming drink [designed to raise blood alcohol levels (BALs) to 0.03 g/dl] were assessed. This was followed by a 2-h self-administration period where subjects could choose to consume up to eight additional drinks (each designed to raise BALs by 0.015 g/dl) or to receive monetary reinforcement for drinks not consumed.

RESULTS

We found that 6 h after patch application, tobacco craving associated with withdrawal relief was decreased, and systolic blood pressure and heart rate were increased in the active patch condition compared to the placebo patch condition. Subjective intoxication in response to the priming drink was attenuated in the active nicotine patch condition compared to 6 h of nicotine deprivation (i.e., placebo patch). During the self-administration period, subjects had longer latencies to start drinking and consequently appeared to consume fewer drinks when administered the active patch compared to the placebo patch.

CONCLUSIONS

In heavy drinkers, transdermal nicotine replacement compared to mild nicotine deprivation attenuated subjective and physiological alcohol responses and delayed the initiation of drinking.

Bupropion and nicotine patch as smoking cessation aids in alcoholics

This is a double-blind placebo-controlled study of sustained-release bupropion as a smoking cessation aid in alcoholics undergoing treatment for their alcoholism. Participants (N=58) were enrolled within 1 week of entry into alcohol treatment from community and Veterans Affairs Substance Use Disorder programs. All participants received nicotine patch and were invited to attend a smoking cessation lecture and group. Cigarette smoking and alcohol outcomes were measured at 6 months. Bupropion when added to nicotine patch did not improve smoking outcomes. One third of participants on bupropion reported discontinuing the drug during weeks 1-4. Participants reported cigarette outcomes with nicotine patch that are similar to those seen in the general population. All study participants significantly reduced cigarette use. Comorbid affective disorder or antipersonality disorder did not affect outcomes. Alcohol outcomes were improved in those who discontinued cigarettes.

Association between Alcohol Use and Smoking in Adolescent and Young Adult Twins: A Bivariate Genetic Analysis

The association between alcohol use and smoking was examined in a large population-based sample of Dutch twins consisting of three age groups; young adolescent twins aged 12-14 years (n= 650 twin pairs), 15-16-years-old adolescent twins (n= 705 twin pairs), and young adult twins aged 17-25 years (n= 1266 twin pairs). For all three age groups, alcohol use and smoking were correlated (r= 0.5-0.6). Adolescents and young adults who smoked were more likely to drink alcohol than nonsmokers. The relation between alcohol use and smoking was also found within a twin pair; alcohol use in one twin was correlated with smoking in the cotwin. This finding suggested that familial factors contribute to the association between alcohol and tobacco use. With a bivariate genetic model, it was examined to what extent the comorbidity was due to genetic and environmental factors that predispose to both alcohol use and smoking. The genetic analyses showed that the underlying factors that influence alcohol and tobacco use and cause their association were different for adolescent and young adult twins. Initiation of alcohol use and smoking in adolescents (aged 12-16 years) was substantially influenced by the same shared environmental features. Alcohol and tobacco use in young adults were associated due to the same genetic risk factors.

Body Weight Change and Mortality in a Cohort of Elderly Patients Recently Discharged from the Hospital

OBJECTIVES

To evaluate the prognostic significance of weight change in frail elderly patients.

DESIGN

Prospective study.

SETTING

The general medical or surgical wards of a university-affiliated Department of Veterans Affairs hospital.

PARTICIPANTS

Six hundred sixty randomly selected subjects aged 65 or older.

MEASUREMENTS

At admission and discharge, each subject completed a standardized diagnostic evaluation, including demographic variables, and basic medical, functional, and nutritional assessments. Weights were recorded from hospital or clinic visits in the year before admission, during the current hospitalization, and after discharge for a median of 5.6 years. Average yearly intraindividual weight change was calculated using least-squares regression. Associations between intraindividual weight change and mortality were identified using Cox proportional hazards regression.

RESULTS

During the study, 314 subjects (48%) died. A U-shaped association between weight change and mortality was observed. Those who were relatively weight stable (+/-1 kg/y) had the lowest mortality (28%). Compared with this group, the adjusted relative risks (ARR) of death for those who lost 1 or more to less than 3 kg/y and 3 or more kg/y were 2.14 (95% confidence interval (CI)=1.52-3.00) and 3.59 (95% CI=2.58-4.99), respectively. The ARR associated with a weight gain of 1 or more to less than 3 kg/y and 3 or more kg/y was 1.38 (95% CI=0.91-2.10) and 3.73 (95% CI=2.34-5.94), respectively. The amount of bidirectional weight fluctuation (estimated using coefficient of variance) was not significantly associated with mortality.

CONCLUSION

For reasons that are not clear, elderly patients who gain 3 or more kg/y after hospital discharge are at nearly the same risk of mortality as those who lose this amount of weight.

Alcohol consumption and smoking status: the role of smoking cessation

Cigarette smoking is common among persons with alcohol dependence or abuse with as many as 80% of persons who are alcohol dependent also being smokers. Not only is smoking common in persons with heavy alcohol consumption, but also nicotine dependence appears more severe in smokers with a history of alcohol dependence. This combined exposure to both tobacco smoke and alcohol results in major health consequences including additive risks for some diseases such as head and neck cancers. Although modest alcohol consumption has some positive health benefits, smoking typically negates these benefits. The cellular mechanisms impacted by combined smoking and alcohol exposure are poorly understood, but molecular epidemiology approaches are providing insights regarding the importance of effects on oxidant/antioxidant pathways and on metabolic pathways involving the cytochrome P450 system. Given the prevalence of smoking in the alcohol dependent population, smoking cessation in this group has the potential for tremendous impact. In recent years, smoking cessation approaches have been initiated in this population, but much work remains in order to define the optimal smoking cessation strategies for persons in alcohol treatment programs.

Timing of Alcohol and Smoking Cessation (TASC)

Tobacco dependence is prevalent among alcohol dependent patients, and causes increased morbidity and mortality. Concurrent treatment for these disorders may be advantageous, but there are concerns about adverse effects on alcohol treatment outcomes. The Timing of Alcohol and Smoking Cessation (TASC) Study is a randomized controlled clinical trial to compare the effectiveness of smoking cessation treatment offered concurrently or six months following intensive rehabilitation for alcohol dependence. This paper describes the study design and baseline characteristics of the study population. Participants were current smokers in intensive alcohol dependence treatment, with willingness to consider quitting smoking. Smoking intervention offered behavioral and pharmacological treatment. One thousand nine hundred forty-three patients were screened for enrollment; 499 were eligible and participated (26%). We describe demographic characteristics, smoking behavior and attitudes among participants and nonparticipants toward smoking cessation and drinking. We conclude that there is considerable interest in smoking cessation in alcohol dependent treatment populations, and recruitment to research studies is feasible.

A 60-year follow-up of alcoholic men

AIMS

To study the course of male alcohol abuse from age 20 to age 70-80 years.

DESIGN

A prospective multi-disciplinary follow-up of two community cohorts of adolescent males from 1940 until the present.

SETTING AND PARTICIPANTS

Two hundred and sixty-eight former Harvard undergraduates (college sample) and 456 non-delinquent, socially disadvantaged Boston adolescents (core city sample).

MEASUREMENTS

Since adolescence these cohorts have been followed by repeated interview, questionnaires and physical examination. The college cohort has been followed until age 80 and the younger core city cohort until age 70. DSM-III criteria were used to ascertain alcohol abuse and alcohol dependence. At some point during their lives, 54 (20%) of the college men and 140 (31%) of the core city men met criteria for alcohol abuse. Outcome categories were mortality, continued alcohol abuse and stable remission.

FINDINGS AND CONCLUSIONS

These socially divergent cohorts resembled each other in four respects. First, by age 70 chronic alcohol dependence was rare; this was due both to death and to stable abstinence. By age 70, 54% of the 72 successfully followed alcohol-dependent core city men had died, 32% were abstinent, 1% were controlled drinkers and only 12% were known to be still abusing alcohol. By age 70, 58% of the 19 successfully followed college alcohol-dependent men had died, 21% were abstinent, 10.5% were controlled drinkers and only 10.5% were known to be still abusing alcohol. Secondly, in both samples alcohol abuse could persist for decades without remission, death or progression to dependence. Thirdly, among both samples prior alcohol dependence and AA attendance were the two best predictors of sustained abstinence. Fourthly, few life-time symptoms of alcohol abuse were the best predictor of sustained return to controlled-drinking.

Treatment of tobacco dependence in alcoholics

Because of the high morbidity and mortality that alcoholic smokers experience from tobacco-caused diseases, treatment for tobacco dependence among alcoholics is warranted. Much progress has been made during the last decade in addressing tobacco dependence in alcoholism treatment units. Treatment of tobacco dependence in alcoholic smokers does not seem to cause excessive relapse to drinking and, in fact, stopping smoking may enhance abstinence from drinking. Therefore, treatment for alcoholic smokers should take place whenever and wherever the patient comes in contact with the health care system. Because alcoholic smokers as a rule are more dependent on nicotine than their nonalcoholic counterparts, they may need more intensive pharmacotherapy and behavioral therapy. Because many of them have experienced 12-step approaches to recovery, that same technology can be used to initiate and maintain abstinence from tobacco use. Moreover, several pharmacologic options exist to treat tobacco dependence in alcoholic smokers. However, the efficacy of several pharmacologic therapies for alcoholic smokers needs to be tested. In addition, further research is needed on effective treatments for recovering alcoholics of various racial/ethnic backgrounds.

Tobacco and alcohol use and medical symptoms among cocaine dependent patients

Despite the widespread use of tobacco and alcohol by illicit drug users, the medical effects of smoking and alcohol use remain understudied among such individuals. We investigated the relationship between smoking and alcohol use, and medical symptoms among 125 cocaine dependent patients. Subjects were assessed for smoking, alcohol use, and medical problems using a standardized self-report instrument (MILCOM). Medical symptoms were compared among nonsmokers, moderate smokers (less than 10 cigarettes per day), and heavy smokers (10 or more cigarettes per day) using partial chi-square statistics. Similar comparisons of medical symptoms were made between alcohol users (more than 2 drinks per day) and nonusers. Contrary to our expectations, there were no significant differences between nonsmokers, moderate smokers, and heavy smokers across most of the 14 major medical systems. However, regardless of the level of cocaine use, nonsmokers reported the fewest symptoms on the general subscale (p < 0.05) while moderate smokers reported the most nose/throat and respiratory symptoms (p < 0.01) among the three groups. As expected, significant relationships were observed between medical symptoms and alcohol use. Alcohol users reported more respiratory (p < 0.05), cardiovascular (p < 0.01), digestive (p < 0.05), head/neck (p < 0.001), eye (p < 0.01), and general (p < 0.05) symptoms than nonusers. While the findings generally support the link between alcohol and medical problems, it seems that the relationship between medical symptoms and smoking among cocaine patients may be more complex than that observed in the general population.

Conjoint smoking and drinking: a case for dual-substance intervention among young emergency department patients

OBJECTIVES

To better understand conjoint smoking and drinking among young adult emergency department (ED) patients, the purposes of this investigation were: 1) to assess the prevalence of conjoint use; 2) to determine the factors associated with conjoint alcohol use and smoking; and 3) to address the implications for future ED-based investigation of dual-substance intervention.

METHODS

Data for this investigation were obtained from a battery of questionnaires administered to the routine-care patients during an alcohol screening in the ED, which was part of a larger alcohol intervention study.

RESULTS

Study findings revealed that a majority of patients with self-reported alcohol-related problems were smokers. In fact, drinkers who smoked were likely to be pack-a-day smokers. Among the study sample, being female, having low education levels (e.g., high school education or less), having some emotional problems, and currently using marijuana were risk factors for conjoint smoking and drinking.

CONCLUSIONS

Conjoint users were identifiable through brief screening. Given the prevalence of conjoint smoking and alcohol use among the ED sample and a specific set of risk factors, tailored intervention for alcohol and nicotine dependence may be an important and opportunistic clinical ED service.

Response to nicotine dependence treatment in smokers with current and past alcohol problems

Smoking prevalence among alcoholics is high, and evidence indicates that smokers with a history of alcohol abuse may have more difficulty quitting cigarette smoking. This study is a post hoc analysis comparing the smoking cessation rates of smokers with active or past alcohol problems to the rates in smokers with no history of alcohol problems who were participants in a randomized, controlled trial of smoking cessation therapy. Subjects received either 44 mg/24 hour or 22 mg/24 hour nicotine patch for 4 or 6 weeks, respectively, followed by a tapering schedule to complete 8 weeks of therapy and a randomly assigned behavioral intervention (minimal, brief individual counseling, group therapy). The Self-Administered Alcoholism Screening Test (SAAST) score was used to determine alcohol group assignment (no alcohol problems < 7; active alcohol problems > or = 7 and still drinking; past alcohol problems if not drinking due to a past history of alcohol problems). Among 382 subjects (171 men and 211 women), 281 had no alcohol problems (74%), 53 had past alcohol problems (14%), and 48 had active alcohol problems (13%). Smoking cessation rates assessed at both weeks 4 and 8 were significantly different across groups (p = 0.026 and 0.002 at weeks 4 and 8, respectively) with lower rates in the groups with past and active alcohol problems when compared to the "no problem" group. At week 26, subjects with past alcohol problems were less likely to be abstinent from smoking than no problem group subjects, but this was not statistically significant (odds ratio = 0.49, 95% confidence interval 0.22-->1.08). In the short term, smokers with past or active alcohol problems are less likely to quit smoking compared to those with no alcohol problems when treated with nicotine patch therapy for smoking cessation.

Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients

OBJECTIVE

The purpose of this study was to explore the value of patient self-report assessment in heart transplant candidacy evaluation, utilizing the Millon Behavioral Health Inventory (MBHI). Patient's MBHI measures were related to important pretransplant patient characteristics and posttransplant measures of health behavior, medical morbidity, and mortality.

METHOD

Ninety heart patients with end-stage cardiac disease completed the MBHI during pretransplant candidacy evaluations, and also were interviewed concerning their coping effectiveness, support resources, and compliance history. Postransplant follow-up of 61 living and 29 deceased patients included measures of survival time, postsurgical medical care, rejection and infection episodes, and nurse ratings of medication compliance and problematic interpersonal health behaviors.

RESULTS

The MBHI coping scales were found to significantly discriminate good and poor pretransplant compliance, and interview judgments of good and poor coping and support resources, with modest accuracy. The MBHI also was superior to these interview judgments in predicting posttransplant survival time and medical care used. Certain scales were also positively associated with physical parameters of pretransplant and posttransplant status.

CONCLUSIONS

Patient self-report with the MBHI can contribute to identification of patients at risk for a problematic outcome with transplant, by providing information pertinent to clinical decision making and outcome management analysis with this special population of cardiac patients.

Natural history of male psychological health, XIV: Relationship of mood disorder vulnerability to physical health

OBJECTIVE

A 55-year prospective study attempted to determine the antecedents and consequences of positive mental and physical health in adult men. A substudy was conducted to look at the late-life physical health of men selected to be as unlike men with major depressive disorder as possible.

METHOD

Of 237 men selected for health and followed since college, 64 undistressed men had never used mood-altering drugs or consulted a psychiatrist before the age of 50. The health at age 70 of these 64 men was compared with that of 20 men classified as depressed at age 70, 109 men classified as neither healthy nor depressed at age 70, and 44 men classified as having alcohol dependence or abuse at age 70.

RESULTS

At age 70, the 64 undistressed men enjoyed significantly better health than the 109 men in the intermediate group. Only three (5%) of the 64 undistressed men were dead or disabled by age 70, compared with 30 (28%) of the 109 men in the intermediate group and nine (45%) of the 20 depressed men. The mean age of the subjects' maternal grandfathers at death also significantly differentiated the three groups. The differences in longevity among the three groups could not be explained by personality disorder, by cigarette, dietary, or alcohol abuse, or by longevity of the subjects' other first-degree ancestors.

CONCLUSIONS

These findings lend support to the hypothesis that risk of affective disorder may lie along a continuum. At one extreme may be men with stable lifestyles, a lifelong resistance to mood disorder, and unusually good physical health in late life. At the other extreme of the continuum may be men with vulnerability to mood disorder and accelerated physical aging.

Mortality in men with drinking problems: a 20-year follow-up

This study presents mortality data from a 20-year follow-up of 99 married men with drinking problems. Forty-four of the sample had died and death certificates were obtained on 43. Cause of death was classified according to the Ninth Revision of the International Classification of Diseases. Most of the mortality excess was in the 45-54 year age group. The observed/expected mortality ratio was 3.64 for the group as a whole, 2.93 for the moderately dependent group and 4.41 for the severely dependent group. The commonest causes of death were carcinoma of the bronchus and diseases of the circulatory system. Cause of death was analysed in terms of years of life lost. The number of years of life lost per death was highest for injury and poisoning. Only four of the 43 death certificates obtained mentioned "chronic alcoholism".

Evidence that the type 1/type 2 dichotomy in alcoholism must be re-examined

Studies supporting Cloninger's original Type 1/Type 2 hypothesis for classifying the genetic transmission of alcoholism have sometimes failed to control for important sources of potential bias. First, the environmental effects of parental alcoholism must be distinguished from the genetic effects of parental alcoholism. Secondly, antisocial personality disorder must be distinguished from alcohol dependence. Thirdly, to control for developmental effects a cohort of alcoholics should be followed into late mid-life. The present report, a 50-year prospective study of the development of alcoholism in two community samples of 456 disadvantaged youth and 204 Harvard graduates, addresses these three potential sources of bias. In this report the age of onset of alcoholism and the degree of antisocial symptomatology was correlated with disturbed family environment but was quite independent of the presence or absence of a heredity positive for alcoholism. The reasons why such findings threaten the validity of the Type 1/Type 2 hypothesis are discussed.

Nicotine dependence treatment during inpatient treatment for other addictions: a prospective intervention trial

This study assessed the effect of treating nicotine dependence in smokers undergoing inpatient treatment for other addictions. It was a prospective, nonrandomized, controlled trial with a 1-year outcome. The subjects were smoking patients (50 controls, 51 in intervention group) in an inpatient addictions treatment unit in a medical center. The enrollment of subjects was sequential: controls were enrolled first; after a 6-week washout period, intervention subjects were enrolled. Controls received usual care, and the intervention group received nicotine dependence treatment consisting of a consultation, 10 intervention sessions, and a structured relapse prevention program. Smoking cessation rate and abstinence from alcohol or other drug use were the main outcome measures. The confirmed smoking cessation rate at 1 year was 11.8% in the intervention group and 0.0% in the control group (p = 0.027). Nicotine dependence intervention did not seen to interfere with abstinence from alcohol or other drugs (1-year relapse rate was 31.4% in the intervention group and 34.0% in controls). In this study, nicotine dependence treatment provided as part of addictive disorders treatment enhanced smoking cessation and did not have a substantial adverse effect on abstinence from the nonnicotine drug of dependence.