How prevalent are alcohol and tobacco use?

The National Institute on Alcohol Abuse and Alcoholism’s (NIAAA’s) 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which is one of the largest comorbidity studies ever conducted, included extensive questions about alcohol and tobacco use and related disorders. NESARC data confirmed the widespread use of alcohol with tobacco: Approximately 46 million adults used both alcohol and tobacco in the past year, and approximately 6.2 million adults reported both an AUD and dependence on nicotine.

Alcohol and tobacco use varied according to gender, age, and ethnicity, with men having higher rates of co-use than women. Younger people tended to have a higher prevalence of AUDs, nicotine dependence, and co-use. Although Whites were more likely to drink alcohol, American Indians/Alaskan Natives were most likely to smoke, or to smoke and drink concurrently. Asians/Native Hawaiians/Pacific Islanders were least likely to smoke or drink, or smoke and drink concurrently.

Alcohol and tobacco use may lead to major health risks when used alone and together. In addition to contributing to traumatic death and injury (e.g., through car crashes), alcohol is associated with chronic liver disease, cancers, cardiovascular disease, acute alcohol poisoning (i.e., alcohol toxicity), and fetal alcohol syndrome. Smoking is associated with lung disease, cancers, and cardiovascular disease. Additionally, a growing body of evidence suggests that these substances might be especially dangerous when they are used together; when combined, alcohol and tobacco dramatically increase the risk of certain cancers.

The American Heart Association estimates that more than 34 percent of the United States population has some form of cardiovascular disease. Tobacco use and alcohol consumption both are major risk factors for various forms of cardiovascular disease. However, little evidence exists to suggest that drinking and smoking together raise the risk more than the sum of their independent effects.

Determining the risk factors for cardiovascular disease is difficult because the issues involved are extremely complex. First, cardiovascular disease encompasses a variety of conditions (such as heart attack, stroke, and hardening or narrowing of the arteries), which result from numerous factors. Second, although tobacco has been shown to raise the risk for cardiovascular disease in a dose-dependent manner – the more a person smokes, the more his or her risk of developing cardiovascular disease increases – alcohol’s effect on cardiovascular disease depends on many factors, including gender, age, and drinking patterns. Overall, moderate drinking appears to reduce the risk for many forms of cardiovascular disease, whereas drinking large amounts of alcohol generally increases the risk.

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ALCOHOL AND TOBACCO

Alcohol and tobacco¹ are among the top causes of preventable deaths in the United States. Moreover, these substances often are used together: Studies have found that people who smoke are much more likely to drink, and people who drink are much more likely to smoke. Dependence on alcohol and tobacco also is correlated: People who are dependent on alcohol are three times more likely then those in the general population to be smokers, and people who are dependent on tobacco are four times more likely than the general population to be dependent on alcohol.

The link between alcohol and tobacco has important implications for those in the alcohol treatment field. Many alcoholics smoke, putting them at high risk for tobacco-related complications including multiple cancers, lung disease, and heart disease (i.e., cardiovascular disease). In fact, statistics suggest that more alcoholics die of tobacco-related illness than die of alcohol-related problems. Also, questions remain as to the best way to treat these co-occurring addictions; some programs target alcoholism first and then address tobacco addiction, whereas others emphasize abstinence from drinking and smoking simultaneously. Effective treatment hinges on a better understanding of how these substances – and their addictions – interact.

Understanding just how alcohol and tobacco interact is challenging. Because co-use is so common, and because both substances work on similar mechanisms in the brain, it’s proving difficult to tease apart individual and combined effects of these drugs. In this Alcohol Alert, we examine the latest research on the interactions between these two substances, including the prevalence of co-occurring tobacco and alcohol use disorders (AUDs), some of the health consequences of combined use, biological mechanisms and genetic vulnerabilities to co-use and dependence, barriers to the treatment of tobacco dependence in patients with alcohol and other drug (AOD) use disorders, therapies that are proving effective in treating co-occurring tobacco and alcohol dependence in depressed patients, and treatment interventions for adolescent patients with co-occurring tobacco and AOD use disorders.