Sociocultural influences on smoking and drinking.

1Research indicates that sociocultural factors influence the initiation and continued use of alcohol and tobacco among adolescents and adults. Few studies have examined the effects of sociocultural factors on the tendency of smokers to drink and drinkers to smoke. However, the limited evidence available suggests that such factors exist and that the strength of the association between alcohol and tobacco use behaviors varies with the levels of alcohol use.

2This article first reviews research on the sociocultural factors that influence whether adolescents begin smoking and/or drinking. The article then discusses similar mechanisms that may sustain alcohol and tobacco use among adults. Some sociocultural factors influence smoking and drinking across much of the adult population. Other factors that predict continued tobacco use among adults might differ for alcohol abstainers, moderate drinkers, heavy drinkers, and recovering alcoholics.

3Although this article discusses adolescent and adult populations separately, a strong, positive relationship exists between alcohol and tobacco use in both age groups. Results from the 1997 National Household Survey on Drug Abuse indicated that among the respondents ages 12 to 17 as well as ages 18 and older, current drinkers were much more likely to be current smokers compared with former drinkers or people who had never consumed alcohol (i.e., “never drinker”) (see table 1). The survey results also showed an especially strong relationship between binge drinking (defined as consuming five or more drinks per occasion) and current smoking among adolescents. Adolescents who reported engaging in binge drinking within the past 30 days were more than five times more likely to smoke than were adolescents who denied participating in binge drinking (76.8 versus 14.1 percent). Adults who reported episodes of binge drinking within the past 30 days were approximately twice as likely as were non-binge-drinking adults to be current smokers.

4The strong association between binge drinking and smoking among adolescents may be attributable, in part, to the fact that both adolescent alcohol use and tobacco use share a number of sociocultural risk factors. Researchers have found that these factors—including family and peer influences, demographics, advertising, economics, and alcohol and tobacco availability—are associated with adolescents’ initial and continued tobacco and alcohol use.

5Adolescents are more likely to smoke cigarettes if their parents, siblings, or friends smoke. In addition, adolescents whose friends, siblings, or parents smoke are more likely to smoke at an earlier age than are other adolescents. Adolescent alcohol use is also associated with drinking by peers, parents, and siblings. Together these findings demonstrate that family and peers exert similar influences on adolescent smoking and drinking.

6Among teens, parent-child relationship factors—such as limited or poor-quality familial attachments; low levels of parental supervision and strictness; inadequate parental monitoring; and lack of parental affection, concern, and involvement—have also been related to smoking and drinking. Data from the Adverse Childhood Experiences Study have further shown that any one of eight childhood stressors, including verbal, physical, or sexual abuse, significantly increases both a youth’s risk of smoking by age 14 and continued tobacco use as an adult.

7National student surveys show that white students, overall, are more likely than Hispanic and African-American students to report engaging in smoking or drinking within the previous 30 days. Hispanic students also are more likely to smoke or drink compared with African-American students. In addition, males generally are more likely than females to report current and frequent smoking as well as current and heavy drinking.

8In their review of multiple studies on teen smoking, found that lower socioeconomic status consistently predicted smoking onset among teens. found that alcohol use was also disproportionately concentrated among economically disadvantaged youth. Similar demographic factors have also been associated with adolescent smoking and drinking and may contribute to the relationship between smoking and drinking among adults.

9In a study of adolescents who, when first interviewed, had never engaged in smoking, found at the 3-year followup that having a favorite cigarette advertisement as well as possessing or being willing to use a tobacco promotional item at the initial interview predicted either future smoking or the increased likelihood of trying tobacco. reported that the age of smoking initiation occurred earlier among adolescents who had a favorite tobacco advertisement, had received tobacco promotional items, or were willing to use tobacco promotional items. Research has also shown that awareness of beer commercials among fifth and sixth graders is significantly related to intentions to drink as adults, suggesting that alcohol advertising may influence adolescents to be more favorably disposed to drinking. Therefore, advertising has been found to be a potential risk factor for both smoking and drinking among adolescents.

10Research suggests that adolescent smokers or drinkers are more likely than adults to reduce or quit smoking or drinking in response to increased cigarette or alcohol prices (see; ). found that 15- to 17-year-olds, compared with 18- to 20-year-olds, were more likely to respond to an increase in cigarette prices by quitting smoking rather than by reducing the number of cigarettes they smoked per day. reported price elasticities of demand for cigarettes of −1.20 for 12- to 17-year-olds and −0.15 for people older than age 35, meaning that a 10-percent increase in the price of cigarettes would lower per capita consumption for these two populations by 12 and 1.5 percent, respectively. Other research suggests that a 10-percent increase in cigarette prices would reduce the number of teens who smoke by 7 percent.

11Alcohol use by young people is also more sensitive to price than drinking among adults. In one study, the price elasticity of demand for heavy drinking was −0.92 for people age 18 and older, compared with −2.24 for those between ages 18 and 21. The authors suggest that adults respond more to increases in the potential future costs or consequences of smoking and drinking, whereas young people are more sensitive to increases in price, because future costs are less important to them and young people have more stringent budget constraints than do adults.

12College students, however, may be less responsive to alcohol prices than are other groups of young people. examined drinking data from 17,000 college students in relation to beer prices and drunk driving laws in the locations of the participating colleges. The results suggested that college students were less responsive to alcohol prices than were other groups but that more severe drunk driving penalties tended to reduce both drinking and binge drinking. These effects were found among underage and older students, both male and female.

13In another study that used data from multiple sources, including surveys of high school seniors conducted as part of the Monitoring the Future (MTF) project, researchers found a negative relationship between alcohol prices and both alcohol use and motor vehicle accident mortality and a positive relationship between college completion rates and alcohol prices. The researchers concluded that increases in Federal taxes on alcoholic beverages are effective in reducing youth alcohol consumption and alcohol-related injuries and deaths. In fact, reported that if the Federal excise tax on beer had been indexed to the rate of inflation since 1951, about 1,660 fewer 18- to 20-year-olds would have been killed in motor vehicle accidents in a typical year between 1982 and 1988. These studies show that adolescents are sensitive to increases in both tobacco and alcohol prices and that they are generally more sensitive to price than are adults.

14The ease of obtaining cigarettes also influences smoking among adolescents. Both the general availability of cigarettes and offers of cigarettes from parents and siblings have been found to predict smoking onset among teens. Vending machines increase the availability of tobacco products to youth and are used more often by children and adolescents than by the general public.

15Marketing practices related to the sale of alcohol and tobacco products, such as advertising, pricing, and availability, have been shown to influence the use of these substances among adults. Alcohol and tobacco advertisements depict drinking and smoking as fun activities that people do to relax and socialize. Advertising has been found to influence consumption among adults as well as youth. A meta-analysis of 48 studies that examined cigarette sales in relation to advertising and other factors, such as price, found that national spending on tobacco advertising was significantly related to tobacco sales. In another study that used data from a national survey of adults, researchers estimated that a 50-percent increase in the price of cigarettes could cause a 12.5-percent decrease in cigarette use. The findings suggest that younger smokers would be more likely than older smokers to quit smoking in response to a price increase and that Hispanic smokers and African-American smokers would be more likely than white smokers to quit. In their review, concluded that increased alcohol taxes and prices generally result in decreased alcohol consumption and related problems. In addition, they reported that research has shown a strong positive relationship between the increased availability of alcoholic beverages and the consequences of alcohol use and abuse.

16Restrictions on the sale and use of alcohol have had complex and controversial effects on alcohol use. Although some groups continue to promote tighter restrictions on use, others argue that the Prohibition (1919–1933) amply demonstrated the ineffectiveness of legal bans on drinking.

17Research suggests that workplace smoking bans and other restrictions on where smoking is allowed, however, may reduce smoking prevalence among people subjected to them. In a review of studies of workplace smoking restrictions, reported that daily smoking rates declined in 18 of 19 studies and that smoking prevalence declined in 17 studies. Both workplace and household smoking restrictions have also been associated with higher rates of quit attempts, lower rates of relapse among smokers who attempted to quit, and higher rates of light smoking among current daily smokers. Another study compared changes in smoking prevalence among smokers employed at smoke-free hospitals with changes in smoking among smokers in the community who were employed at non-smoke-free workplaces.1 Beginning with the smoking ban and continuing for 5 years after implementation, statistically significant differences in the postban quit ratio were observed between smokers employed at the smoke-free hospitals and their counterparts in the community. The overall difference in postban quit ratios remained significant even after adjustment for socioeconomic, demographic, and smoking-intensity variables.

18The extent of tobacco and alcohol use may also be influenced by stress. One theory suggests that people are more likely to use drugs, especially multiple drugs, when unable to cope with stressful situations. A 1995 review of the literature concluded that adults often use alcohol and tobacco for similar reasons, but the coping functions for alcohol use are more likely to involve distraction and forgetting, whereas the coping functions for smoking were related to increased attention and concentration.

19A recent review of the “smoke to cope” literature portrays a more complex relationship between stress and smoking. Although most smokers report that cigarettes help them relax, several studies indicate that smokers are more anxious overall than are nonsmokers and that former smokers who maintain complete nicotine abstinence for at least 6 months report significant reductions in their stress levels. These findings suggest that nicotine-dependent smokers must smoke on a regular basis to cope with the withdrawal symptoms experienced when nicotine blood levels drop between cigarettes. Smoking is thus a major contributor to stress and a conditioned response to adverse moods.

20Although much has been learned about sociocultural influences on adult tobacco use, the available literature does not satisfactorily explain the substantial variability in prevalence of smoking within the alcohol use levels displayed in table 1. Some insights on possible factors associated with this variability can be obtained by considering various levels of alcohol use sequentially.

21Adults who have rarely or never consumed 12 or more drinks per year have tobacco-use patterns that differ markedly from moderate drinkers, heavy drinkers, and recovering alcoholics or problem drinkers. As the data in table 1 indicate, smoking is relatively uncommon among nondrinkers. Factors that discourage tobacco use in this group have not been studied extensively to date, although the tendency for positive health behaviors to cluster in individuals is well established. In addition, several religious groups, including Mormons and Seventh Day Adventists, strongly oppose the use of both alcohol and tobacco.

22The U.S. Government has defined moderate drinking as no more than one drink2 per day for women and no more than two drinks per day for men. Similar to findings among adolescents, the sociocultural factors responsible for higher rates of tobacco use among adult moderate drinkers are poorly understood. Like adolescents, moderate drinkers may receive more frequent cues to smoke than do non-drinkers if many of their peers, family members, and social acquaintances also drink and smoke. These cues, along with the addictive nature of tobacco, may encourage continued smoking and compromise efforts to quit.

23Research with smokers who drink suggests that drinking prompts smoking. Participants in one study used small portable computers to record when they smoked and what else they were doing at the time. The computers also randomly “beeped” the participants to determine what they were doing during periods when they were not smoking. The participants were almost twice as likely to report recent drinking when they had been smoking. The results of this study are consistent with the theory that drinking influences smoking by releasing inhibitions that restrain smoking.

24Smoking is especially prevalent among heavy drinkers, including people diagnosed with alcohol abuse or alcoholism.3 Table 2 summarizes the results of six studies published from 1967 to 1993 that reported the prevalence of tobacco use among alcoholics recently admitted for treatment. Until the early 1990s, about 90 percent of all such patients were regular smokers. More recent data suggest a marked decline in smoking prevalence in this population. Studies reported in 1996 and 1997 reported tobacco use rates among alcohol treatment patients of 75 and 71 percent, respectively.

25Stress may influence levels of both smoking and drinking among heavy drinkers, as it does among moderate drinkers. In addition, depression has been associated with smoking and severity of nicotine dependence and with alcohol dependence, although research has not determined whether alcohol dependence precipitates depression or results from it (see ).

26In a national survey of adults, smoking and drinking were both associated with self-reported negative moods (e.g., depression, loneliness, restlessness, boredom, and feeling upset). Women who scored the highest on a scale of negative moods were almost three times more likely to smoke than were women who had a score of zero. Among men, the odds of smoking also increased with negative mood scores. Women with high negative mood scores were not significantly more likely to drink heavily (i.e., to consume an average of two or more drinks per day). However, among men, the odds of being a heavy drinker (i.e., of consuming an average of three or more drinks per day) more than tripled for those with the highest levels of negative moods compared with men with no negative moods. Negative moods also were associated with combined smoking and drinking. Men with the highest negative mood scores were four times more likely to combine smoking and heavy drinking than were men with no negative moods. The authors concluded that emotional health status and addictive behaviors were “sufficiently related to warrant increased public health initiatives that attempt to address both issues together rather than one at a time” (, p. 8).

27Although several studies have reported encouraging data on the ability of recovering alcoholics to quit smoking, randomized clinical trial data suggest that most smokers who receive intensive treatment for a history of alcohol abuse or alcoholism continue to smoke long after learning to control their drinking. In addition, many continue to smoke heavily. In a longitudinal study of 575 adult smokers who completed intensive residential treatment for alcohol problems in the Midwest in 1995, 92 percent were still daily smokers 12 months after discharge from treatment. About one-half (49 percent) smoked an average of one or more packs of cigarettes per day.

28Historically, three sociocultural mechanisms have influenced continued smoking among recovering alcoholics and problem drinkers. The first of these can be attributed to the widespread impact of Alcoholics Anonymous (AA) on recovering alcoholics in the United States. In addition to its well-known 12-step program, AA uses a number of pithy aphorisms to guide everyday behavior. One of the most important of these is “ First things first.” AA teaches its members that their primary responsibility is to become and remain sober. Often, members are advised to avoid tackling new challenges, like quitting smoking, until they are confident about their ability to remain sober even when under additional stress. A popular book published by AA uses a tobacco-related anecdote to illustrate this principle. The story reviews the case of an alcoholic whose wife “nagged” him to quit smoking after he had successfully stopped drinking. Unfortunately, the reader learns, “ her intolerance finally threw him into a fit of anger,” which resulted in his becoming drunk (, p. 135). This vignette was used for many years to justify cigarette smoking during AA meetings. Although nonsmoking AA meetings are now available in most communities, they were rare until the mid-1980s.

29Tobacco use policies at alcohol and other drug treatment centers constitute a second sociocultural factor that likely influences smoking among recovering alcoholics and problem drinkers. A 1982 survey of alcohol treatment inpatient facilities in Washington State found that more than one-half (53 percent) of the treatment staff believed a recovering alcoholic should not be encouraged to quit smoking until he or she had been sober for at least 1 year. About one-fourth (23 percent) of the treatment staff indicated that they did not believe an alcoholic should ever be encouraged to quit smoking. Opinions were strongly associated with a personal history of smoking and alcoholism. Staff members who identified themselves as recovering alcoholics and current smokers were far less likely than staff members who self-identified themselves as nonsmokers with no histories of alcohol problems to report that they had ever personally encouraged an alcoholic to quit smoking.

30Paralleling the profound shift in attitudes toward smoking that occurred across most U.S. communities in the 1980s, a marked change in acceptance of tobacco use was evident in alcohol and other drug treatment facilities by the early 1990s. A 1991 survey of 771 treatment personnel in Nebraska found that only 3 percent of the treatment personnel actively discouraged patients or clients who wanted to quit smoking. However, only 35 percent of the staff members said that they thought recovering alcoholics who smoked should be encouraged to quit early in their sobriety. The most common reason given for a reluctance to encourage smoking cessation was the concern that the stress of trying to quit might adversely affect the patient’s ability to remain sober.

31To address this concern, during 1995 researchers conducted a randomized community intervention trial in 12 residential treatment facilities in Iowa, Kansas, and Nebraska. Patients in one-half of the treatment centers received a four-part intervention to encourage smoking cessation. Patients in the remaining six centers (i.e., the control group) received the usual care provided by those facilities. The results of the study clearly showed that alcoholic patients who smoked could benefit from smoking cessation counseling. After 1 year of followup, 43 percent of the patients who were encouraged to quit smoking were still abstaining from alcohol, compared with 29 percent of the patients in the control centers. These findings do not suggest that smoking cessation efforts among recovering alcoholics will be free of stress, but they do indicate that alcohol treatment facilities can safely provide a socio-cultural climate that explicitly encourages smoking cessation. Findings from other studies have shown that instituting smoking cessation programs in alcohol treatment centers is acceptable to treatment staff and does not adversely affect patient enrollment.

32Evidence of a third sociocultural influence on tobacco use among recovering alcoholics and problem drinkers was suggested by an unanticipated finding in the 12-site randomized community intervention trial previously described. Two of the twelve sites (one tobacco intervention site and one control group site) restricted admission to their programs to alcoholics who were either Native American or Alaska Native. The smoking cessation rates among patients in these programs were nearly twice as high as those observed among all other racial and ethnic groups in the study. Treatment staff in the Native American programs attributed the difference in quit rates to frequent discussions with their patients about the sacred role of tobacco in many Native American communities and its traditional use in various religious ceremonies.

33The information reviewed in this article on the sociocultural influences on smoking and drinking suggests several strategies that health care providers and public health practitioners could use to discourage alcohol and tobacco use and alcohol abuse. In addition to ongoing efforts to restrict adolescent exposure to tobacco and alcohol advertising and discourage sales of these products to minors, intervention efforts targeted toward the well-established association between smoking and drinking could prove beneficial. People with histories of problem drinking should be screened for tobacco use, informed of the added health risks of tobacco use for heavy drinkers, and encouraged to quit smoking. New media campaigns to educate the general public on the additional dangers of smoking for moderate and heavy drinkers would also be appropriate. Dedicating some public health research dollars to the development of smoking cessation programs tailored to the needs and interests of recovering alcoholics would also be useful. The National Institute on Alcohol Abuse and Alcoholism has supported some work in this area, but many important clinical questions remain unanswered.

34Other innovative strategies could be considered as well. State legislatures could be urged to pass laws prohibiting smoking and tobacco purchases in bars and taverns. The entertainment and advertising industries could be encouraged to avoid images of people smoking cigarettes in scenes portraying alcohol use and vice versa. And finally, alcohol treatment facilities could be instructed to completely ban all tobacco use on their premises and require all their employees to be nonsmokers.

35This article has reviewed key findings from the large body of literature on sociocultural mechanisms that encourage tobacco and alcohol use among adolescents and adults. Many of these mechanisms exert similar effects on both alcohol and tobacco use behaviors. Socio-cultural factors that encourage smokers to drink and drinkers to smoke have not received extensive study, but they may account for some of the substantial variation in adult tobacco use rates seen among different levels of alcohol consumption.

36Although studies based on samples of problem drinkers and recovering alcoholics suggest a recent weakening of the association between drinking and smoking that is consistent with changes in societal attitudes toward tobacco and standards of care in alcoholism treatment facilities, the connection may continue to be quite strong among some populations (e.g., polydrug users and depressed adults). “ Hard-core” smokers and drinkers may particularly benefit from additional research on sociocultural mechanisms that strengthen the association between these behaviors. Such research may identify new opportunities for treatment and prevention and promote changes in public health policy that would further discourage concurrent use of tobacco and alcohol.