Alcohol and tobacco—Can AA Groups help to break the connection?

By Steven A. Schroeder, MD

It is well known that smoking and drinking go together. People who consume alcohol are much more likely to smoke, and vice versa. For those who struggle with alcoholism, the connection is even tighter, with smoking rates among alcoholics reaching up to ~50%. Studies have shown that brain changes caused by smoking and drinking are addictive and different from the use of either substance alone. Use of one substance can lead to the use of the other, and early exposure to either tobacco or alcohol can lead to addiction in later life. Alcohol increases cravings to smoke, decreases the time between cigarettes, and increases smoking frequency. Similarly, smoking increases alcohol craving, decreases its subjective effects, and leads to greater alcohol consumption. Nicotine may lessen the perception of intoxication, thereby leading to more alcohol consumption during heavy drinking episodes (Schroeder SA. Epilogue to Special Issue on Tobacco and Other Substance Use Disorders: Links and Implications. Am J Drug Alcohol Abuse 2017;43(2):226-9).

The combination of smoking and drinking yields worse health outcomes than using only one substance. Smokers are 2 to 3 times more likely to go on drinking binges than nonsmokers, thereby putting themselves at risk for trauma and other unwise behavior. Persons discharged from the Mayo Clinic with diagnoses of alcohol abuse were much more likely to die from smoking-related illnesses than anything else (Hurt RD, Offord KP, Crogham IT, Gomez-Dahl L, Kottke TE, et al. Mortality following Inpatient Addiction Treatment: Role of Tobacco Use in a Community-based Cohort. JAMA 1996;275:1097-103). And the combination of smoking and drinking drives up the risk of cancer greater than either substance by itself.

Historically, smoking has been tolerated by those who cared for persons with drinking problems, including clinicians, families, and those who drank. There were also myths that stopping smoking might exacerbate drinking. But now we know that the opposite is true—those who are able to stop smoking have a better chance of stopping alcohol use and abuse, in addition to the benefits from being smoke-free (Schroeder SA, Morris CD. Confronting a Neglected Epidemic: Tobacco Cessation for Persons with Mental Illnesses and Substance Abuse Problems. Annu Rev Public Health 2010;31:297-314).

Clearly then, stopping smoking should be a key health goal for the 14 million adult Americans who live with chronic alcohol abuse, plus the several million more who go on periodic drinking binges. One potential resource for breaking the tobacco/alcohol connection is Alcoholics Anonymous (AA), a storied American institution currently serving an estimated 1.2 million persons at 55,000 meeting places scattered throughout the country. It is likely that as many as 500,000 AA members continue to smoke, even those who have overcome their alcoholism. Thus, they may face the same fate as AA founders, Bill Wilson and Dr. Bob Smith, both of whom died of smoking-related illnesses. AA as an organization has not endorsed smoking cessation, citing key organizational principles of fidelity to core mission and local chapter autonomy. Nevertheless, we believe that local AA groups could provide unobtrusive smoking cessation assistance for members interested in quitting. The Smoking Cessation Leadership Center is willing to provide free posters containing the blue Quit Now cards (below) that provide instructions on how to call a toll-free quitline. Such callers have about a 30% chance of quitting smoking, which is much higher than the unassisted rate of about 5%. There is some precedent for using these materials, in that Oxford Houses (self-run, self-supported recovery houses that follow the AA 12-step guidelines) in both Oklahoma and Texas have accepted this offer. If you know of any AA groups willing to accept this offer, please notify us at Brian.Clark@ucsf.edu. It is an opportunity to improve health and save lives.