Alcohol and Tobacco: Clinical and Treatment IssuesMark B. Sobell

THIS COMMENTARY ADDRESSES talks presentedat the National Institute on Alcohol Abuse and Alco-

holism (NIAAA) conference on Alcohol and Tobacco:Mechanisms and Treatment, Clinical and Treatment Issuessession. Overall, it was clear from the proceedings that thefield has made considerable advances since the first con-ference a decade ago (Fertig and Allen, 1995). Rather thansummarize the presentations, because summaries appear aspart of these proceedings, this commentary examines gapsin our knowledge base.

BROADEN THE BASE

Most of the presentations during the clinical and treat-ment issues session, as well as most of the literature onalcohol and tobacco problems, focus on severely dependentalcohol abusers. One reason for this is that most of theresearch has been conducted at alcohol treatment pro-grams, most of which are designed for severely dependentalcohol abusers (McCaul and Furst, 1994). However, suchindividuals do not constitute the majority of those who havealcohol problems. The Institute of Medicine (1990), in itsreport Broadening the Base of Treatment for Alcohol Prob-lems, estimated that 80% of individuals who have alcoholproblems are problem drinkers (i.e., have less severe prob-lems) rather than severely dependent alcohol abusers.

As Vaillant and Milofsky (1984) noted many years ago,limiting our knowledge to individuals who are in alcoholtreatment programs provides a biased view of the disorder.This admonition has been borne out by considerable re-search on natural recoveries from alcohol and drug prob-lems (Klingemann et al., 2001). For example, natural re-covery research has found that the majority of people whorecover from alcohol problems do so without enteringtreatment (Sobell et al., 1996). In addition, treated popu-lations are likely to have higher rates of psychiatric comor-bidity compared with individuals who are not in treatment(Kessler et al., 1996). Consequently, to determine accu-rately the smoking cessation rates among alcohol abusers,the full range of alcohol disorders must be considered.

ATTEND TO ANOMALIES

The history of science shows that finding explanations foranomalies can lead to major advances in knowledge (Kuhn,1970). As was clear from the presentations, anomalies areemerging. For example, we heard that alcohol abusers whoachieve moderation recoveries from alcohol problems areas successful at quitting smoking as those who achieveabstinence recoveries. This is curious because the act ofdrinking should elicit a plethora of smoking cues. Also, whydo individuals who have a history of alcohol problems nothave more difficulty quitting smoking than those who donot have a history of alcohol problems? Replicating anom-alies should be a priority because replicable anomalies mustbe explained by any proposed comprehensive theory ofalcohol and tobacco use disorders.

STUDY PSYCHOSOCIAL AND ENVIRONMENTALFACTORS

Several presentations focused heavily on biologicalmechanisms, with little mention of psychosocial or environ-mental factors related to smoking. This is unfortunate, ascigarette smoking is deeply woven into the fabric of societyand change often occurs in a social context. The act ofsmoking has functional significance for smokers (e.g., re-laxation, time out from other activities). At the conference,Dr. Collins reframed this issue as a need to develop sec-ondary reinforcement models of smoking. Such models(e.g., access to an enriched environment contingent onsmoking) might be an excellent vehicle for linking potentialhuman and animal studies.

MORE LONGITUDINAL RESEARCH IS NEEDED

Unfortunately, although most research on the relation-ship between alcohol and tobacco use is cross-sectional,both alcohol problems and tobacco use tend to be recur-rent. Longitudinal research can address fluctuations overtime using a prospective design, and the value of prospec-tive versus retrospective methods for studying maintenanceof smoking cessation has been demonstrated (Shiffman etal., 1997). Longitudinal studies also would be helpful forstudying interactive (alcohol, tobacco) cue reactivity andfor studying the temporal sequence of cessation.

NICOTINE MAINTENANCE

It was clear from the presentations, and particularly fromthat of Dr. Hurt, that people who have alcohol problems

From the Center for Psychological Studies, Nova Southeastern University,Fort Lauderdale, Florida.

Received for publication August 2, 2002; accepted September 5, 2002.Reprint requests: Reprint requests: Mark B. Sobell, PhD, Nova Southeast-

ern University, Center for Psychological Studies, 3301 College Avenue, FortLauderdale, FL 33314; Fax: 954-262-3895; E-mail: sobellm@nova.edu

Copyright © 2002 by the Research Society on Alcoholism.

DOI: 10.1097/01.ALC.0000041008.52475.C5

0145-6008/02/2612-1954$03.00/0ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH

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and also smoke cigarettes have increased morbidity andmortality. Because long-term smoking cessation rates arelow, one way to decrease smoking-related health problemswhile developing better smoking cessation treatments is tofocus more research on switching smokers to alternativesources of nicotine (inhaler, gum, patch). The objective,however, would be maintenance rather than cessation ofuse.

IDENTIFYING SUBTYPES

Because of the large number of individuals who havetobacco and alcohol disorders, it is reasonable to expectthat differences between subgroups of drinkers and smok-ers might have clinical importance. For example, evidencepresented at this conference was consistent with previousfindings suggesting that it is important to know whether anindividual who has alcohol and tobacco problems is alsodepressed (Pomerleau et al., 1997). It seems clear that thetime has come to move beyond simplistic references to“alcohol abusers who smoke.”

STUDY ALCOHOL ABUSERS WHO HAVE NEVERSMOKED

As reflected in the findings presented at the conferenceby L. Sobell, some alcohol abusers (e.g., 10–20%) neverbecome regular smokers (see also Hughes, 1996). Studyingthis relatively unresearched group might provide insightsinto why some people become addicted to cigarettes andothers do not.

CONCLUSION

In summary, the conference was successful in presentingnew knowledge and in provoking thought, and alcohol and

tobacco researchers are to be commended for joiningforces to address both alcohol and tobacco problems. Al-though much more is known about concurrent alcohol andtobacco problems than was known a decade ago, muchremains to be learned.

REFERENCES

Fertig JB, Allen JA (1995) Alcohol and Tobacco: From Basic Science toClinical Practice (NIAAA Research Monograph No. 30). National Insti-tute on Alcohol Abuse and Alcoholism, Bethesda, MD.

Hughes JR (1996) Treating smokers with current or past alcohol depen-dence. Am J Health Behav 20:286–290.

Institute of Medicine (1990) Broadening the Base of Treatment for AlcoholProblems. National Academy Press, Washington, DC.

Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ(1996) The epidemiology of co-occurring addictive and mental disor-ders: implications for prevention and service utilization. Am J Ortho-psychiatry 66:17–31.

Klingemann HK, Sobell LC, Barker J, Blomqvist J, Cloud W, EllingstadTP, Finfgeld D, Granfield R, Hodgins D, Hunt G, Junker C, Moggi F,Peele S, Smart R, Sobell MB, Tucker J (2001) Promoting Self-ChangeFrom Problem Substance Use: Implications for Policy, Prevention andTreatment. Kluwer Academic Publishers, Boston, MA.

Kuhn TS (1970) The Structure of Scientific Revolutions. University ofChicago, Chicago.

McCaul ME, Furst J (1994) Alcoholism treatment in the United States.Alcohol Health Res World 18:253–260.

Pomerleau CS, Aubin HJ, Pomerleau OF (1997) Self-reported alcohol usepatterns in a sample of male and female heavy smokers. J Addict Dis16:19–24.

Shiffman S, Hufford M, Hickcox M, Paty JA, Gnys M, Kassel JD (1997)Remember that? A comparison of real-time versus retrospective recallof smoking lapses. J Consult Clin Psychol 65:292–300.

Sobell LC, Cunningham JA, Sobell MB (1996) Recovery from alcoholproblems with and without treatment: prevalence in two populationsurveys. Am J Public Health 86:966–972.

Vaillant GE, Milofsky ES (1984) Natural history of male alcoholism: pathsto recovery, in Longitudinal Research in Alcoholism (Goodwin DW,Dusen KTV, Mednick SA eds) pp 53–71. Kluwer-Nijhoff Publishing,Boston.

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