The Author 2007. Published by Oxford University Press on behalf of the Medical Council on Alcohol.
Concurrent alcohol and tobacco use during early adolescence characterizes a group at risk
1 Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim
2 Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health, Mannheim
3 Department of Psychology, Division of Clinical Psychology, University of Potsdam, Potsdam, Germany
* Author to whom correspondence should be addressed at: Central Institute of Mental Health, Department of Child and Adolescent Psychiatry and Psychotherapy, P.O. Box 122120, D-68072 Mannheim, Germany. Tel: +49-621-1703-4902; Fax: +49-621-1703-1205; E-mail: manfred.laucht{at}zi-mannheim.de
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Aims: To investigate whether concurrent alcohol and tobacco use during early adolescence characterizes a subgroup that differs from users of one substance only regarding several risk factors for later substance use problems. Methods: Participants were from a prospective longitudinal cohort study of 384 children at risk for later psychopathology, with the majority being born with obstetric complications and psychosocial adversities. Assessments of adolescent drug consumption and related intrapersonal characteristics were obtained at age 15. Results: Compared to consumers of alcohol only, 15-year-olds drinking and smoking during the same time period (past 4 weeks) had significantly higher levels of consumption and more excessive use of alcohol, started drinking at an earlier age, had higher scores on the Fagerström Test for Nicotine Dependence, and more cannabis use. This group could be distinguished from users of alcohol only by higher novelty seeking and more positive alcohol effect expectancies. Compared to consumers of tobacco only, concurrent users reported higher nicotine dependence and more cannabis use. No significant differences were observed regarding frequency and age at initiation of tobacco use, tobacco-related sensitivity, self-efficacy and instrumentality as well as novelty seeking. Conclusions: Concurrent alcohol and tobacco use during early adolescence is associated with characteristics that are well known as risk factors for later alcohol use problems and dependence and that should be targeted by prevention programs.
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Introduction |
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A positive association between smoking and alcohol use in adolescents has been demonstrated in various studies (e.g. Koopmans et al., 1997
; Flay et al., 1998). The majority of current tobacco smokers also consume alcohol, whereas the proportion of current alcohol drinkers who also smoke tobacco is considerably smaller. Among adolescents in the US National Household Survey, the prevalence of concurrent alcohol and tobacco use within the previous year comes to 20% (Anthony and Echeagaray-Wagner, 2000). As diary data suggest, the most common consumption pattern in adolescents is the concurrent use within day, especially during the week-ends, as compared to the co-occurrence of drinking and smoking within 1-, 2-, and 3-week intervals (Dierker et al.,2006). This finding is in line with the fact that the community experience plays an important role for the consumption of tobacco and alcohol in adolescents.
Research in adolescence and young adulthood has confirmed the significance of both smoking and drinking in mapping the initiation and escalation of the other (Duncan et al., 1998; Jensen et al., 2003). Smoking initiation and persistence were found to be a function of prior drinking and to a lesser extent, drinking initiation and persistence were established as a function of prior smoking (Jackson et al., 2002). In other studies, adolescents reporting binge drinking in the past 30 days were more than five times more likely to smoke than adolescents who denied participating in binge drinking (Bobo and Husten, 2000). Concurrent smoking and drinking in adolescence has also been identified as a risk factor for later alcohol problems and dependence (Madden and Heath, 2002; John et al., 2003). Co-occurrence risks are greatest among youth reporting high total alcohol consumption, drinking problems or symptoms of alcohol abuse (Weitzman and Chen, 2005).
Whereas the association between smoking and drinking during adolescence has been well established, the underlying mechanisms are still discussed. Several studies suggest that the strong link between the use of tobacco and alcohol (and cannabis as well) could be explained by a common factor representing the individual's vulnerability to substance use in general. Behavioural disinhibition has been reported to be an universal risk factor for substance use and substance use disorder (e.g. McGue et al., 1997; Conway et al., 2002) as well as related personality traits like novelty seeking (Cloninger et al., 1988; Heath et al., 1995). Moreover, several studies have indicated that the sensitivity to the positive effects of the initial dose of tobacco leads to regular smoking and the development of dependence (e.g. Pomerleau et al., 1998; DiFranza et al., 2004). Equally, a low level of response to the acute (negative) effects of alcohol has been established as a partially heritable trait that is associated with an increased risk of excessive alcohol intake and alcohol dependence (Schuckit and Smith, 1996). Research has also demonstrated a consistent relationship between the effect expectancies capturing individual drinking and smoking motivations and later substance use and abuse (Brown et al., 1987; Mittag and Jerusalem, 1999). Further indicators of the individual's vulnerability to substance use include positive attitudes toward drinking and smoking (Ritchey et al., 2001).
In addition, twin studies provide ample evidence for a shared genetic vulnerability for regular smoking and alcohol dependence (Madden and Heath, 2002). Direct functional interactions between cigarette smoking and drinking have been revealed that may explain their simultaneous use. For example, male healthy light smokers drank significantly more in an experiment involving voluntary alcohol self-administration if they concurrently received a small nicotine dose than after receiving placebo. This was true for males only, while in females the opposite effect was seen (Acheson et al., 2005)
The objective of the present study is to demonstrate that concurrent alcohol and tobacco use in early adolescence is associated with a pattern of characteristics that are considered as risk factors for later substance use problems. More precisely, we want to strengthen the evidence that even at an early stage of substance use, the group of smoking and drinking adolescents can be clearly distinguished from single substance users by higher levels of substance use and misuse as well as by a younger age of initiation. The present study intends to confirm the existing evidence coming mainly from North American cohorts and older samples using data of 15-year-olds from a European (German) high-risk community sample. In a second step, a number of intrapersonal factors that were suggested as possible indicators of elevated vulnerability to drug abuse were analysed with respect to their association with concurrent smoking and drinking. To our knowledge, the group of concurrent smoking and drinking adolescents has not yet been characterised with respect to the sensitivity to tobacco and alcohol as well as to the alcohol and tobacco effect expectancies.
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Participants
This investigation was conducted as part of the ongoing Mannheim Study of Risk Children, a prospective longitudinal study following children at risk for later psychopathology from birth to adolescence, with the majority suffering from obstetric complications and growing up in family adversity. The initial sample consisted of 384 children of predominantly (> 99.0%) European descent born between 1986–88 in the Rhine-Neckar region of Germany. Additional details on this sample have been reported previously (Laucht et al., 2000
). According to the design of the study, families from psychosocially disadvantaged backgrounds were overrepresented. Assessments were conducted at regular intervals throughout childhood (at the ages of 3 months, 2, 4, 8 and 11 years), most recently at age 15. Of the initial sample, 18 (4.7%) were excluded because of severe handicaps (IQ<70 or neurological disorder) and 28 (7.3%) were dropouts. The actual investigation included 326 adolescents (157 male, 169 female) for whom complete data of the 15-year-assessment were available. At the time of the investigation the adolescents had a mean age of 14.9 years (range: 14.0–16.4; standard deviation: 0.4). Male and female adolescents did not differ in age. The study was approved by the ethics committee of the University of Heidelberg and all participants and their parents gave their written informed consent.
Assessment
At age 15, adolescents completed questionnaires at home regarding their substance use and related behaviours and participated in a 4-h session at our institute where a number of assessments were conducted including a psychiatric interview with the adolescents and their parents (Schedule for Affective Disorders and Schizophrenia in School Age Children K-SADS-PL, Kaufman et al., 2005), questionnaires on adolescent behaviour problems (Youth Self Report and Child Behaviour Checklist, Achenbach, 1991) and EEG recording (baseline EEG activity, event-related potentials within a Continuous Performance Task, Brandeis et al., 2002). In addition, parents were questioned about their mental health and their substance use behaviour using the Structured Clinical Interview for DSM-IV Axis 1 Disorders (German version by Wittchen et al., 1997). In the present investigation data on adolescent substance use and related behaviours are reported.
Tobacco use
Adolescents were administered a smoking inventory including age at smoking initiation, lifetime tobacco use, frequency of current (past month) use, and quantity of cigarettes smoked per day. Prevalence of smoking during last month (yes or no) was used to assign the participants to the consumer groups. The inventory is part of the Substance Use Questionnaire designed by Müller and Abbet (1991) in collaboration with the World Health Organization. The Substance Use Questionnaire has been used in a large-scale Swiss epidemiological study on the frequency and correlates of substance use among preadolescents and adolescents and has demonstrated strong convergent validity (Steinhausen and Metzke, 1998). Responses were combined into a four-level variable to measure the smoking score that reflects both the frequency and the quantity of smoking: (i) never used, (ii) experimental use (smoked up to once per month), (iii) regular use (at least weekly), (iv) dependent use (daily smoking >10 cigarettes per day). The degree of nicotine dependence was measured with the Fagerström Test for Nicotine Dependence (Heatherton et al., 1991), that showed a good internal consistency (
= 0.72) in the present sample.
Alcohol use
Data concerning alcohol consumption were also assessed via the Substance Use Questionnaire, including lifetime alcohol use, age at drinking initiation, current (last month) use and the prevalence of being drunk. Prevalence of drinking alcohol last month (yes or no) was used to assign the participants to the consumer groups. In addition, the amount of alcohol intake during the past 6 months was assessed with the Lifetime Drinking History (Skinner and Sheu, 1982). Measures of the mean number of standard drinks (each with 8–12 g alcohol) consumed per month and the maximum number of drinks consumed per occasion were derived. The Lifetime Drinking History had a test-retest-reliability of 0.67–0.90 (Lemmens, 1998), and the criterion validity assessed as correlation to FORM 90 was about 0.47–0.58 (Scheurich et al., 2005). Using the information for the maximum amount of alcohol consumed per occasion, a measure of binge drinking was formed. For male participants, binge drinking was defined by the consumption of at least five standard drinks per occasion, for females, the criterion was met by four standard drinks. These values correspond to the threshold for high-risk alcohol consumption of the World Health Organization (2000). Lifetime prevalence of cannabis use was also assessed with the Substance Use Questionnaire.
Consumer groups Based on the information about the prevalence of the current tobacco and alcohol use, four sub-groups were established: Adolescents that neither smoked nor drunk alcohol during the last month (group 1), adolescents that only smoked (group 2), adolescents that only consumed alcohol (group 3) and those, who both smoked and drank alcohol in this period (group 4).
Sensitivity to tobacco
The initial sensitivity to nicotine, a measure for the subjective sensations upon first smoking, was assessed with a German translation of a questionnaire by Pomerleau et al. (1998). A sum score was calculated based on three items covering pleasurable sensations in general, pleasurable rush and relaxation with high scores representing higher sensitivity to the positive effects of nicotine.
Sensitivity to alcohol
The level of response to alcohol was measured using the Self Rating of the Effects of Alcohol Questionnaire (Schuckit et al., 1997a). This instrument asks subjects to list the number of standard drinks required to reach up to four levels of intoxication (an initial feeling of intoxication, slurred speech, stumbling gait, passing out). As the sensitivity to the effects of alcohol changes over time and by exposure to alcohol, these questions referred to the first five drinking occasions as a measure of initial sensitivity. The mean of the four items was used, with high scores indicating low sensitivity to the effects of alcohol. The test-retest reliability of the Self Rating of the Effects of Alcohol was 0.80 after 1 year (Schuckit et al., 1997b).
Temperament
To assess adolescent novelty seeking, a version of the Junior Temperament and Character Inventory JTCI/12–18 (Cloninger et al., 1993) was administered that captures four temperament traits of adolescents. The psychometric characteristics of the instrument were confirmed for the German translation (Schmeck et al., 2001). Internal consistency of the novelty seeking scale was = 0.80 in our sample.
Self-efficacy concerning smoking
Self-efficacy expectations concerning smoking were obtained by applying a short form of a scale developed by Leppin and Nordlohne (1993). On the basis of 10 four-step items the adolescents self-evaluated how difficult it would be for them to resist to smoking in certain situations, for example ’When you are together with others, who are smoking’. In order to allow for the interpretation that high values indicate positive expectations, the polarity of the answers was reversed. Internal consistency reported by Mittag and Jerusalem (1999) was 0.96 and 0.86 in our study.
Instrumentality of tobacco
The expectations concerning the instrumentality of tobacco consumption were assessed via a scale also developed by Leppin and Nordlohne (1993). The 17 items had a four-step answer format (approval to disapproval) and referred to the functionality of smoking in different spheres of the adolescents, for example with regard to social relationships or problem solving and affect regulation (i.e. ’When I smoke (or would smoke), I feel less nervous.’). Internal consistency reported by Mittag and Jerusalem (1999) was 0.95 and 0.77 in our study.
Alcohol effect expectancies
Expectancies associated with the effect of alcohol were assessed with a short version of the Alcohol Expectancy Questionnaire (Brown et al., 1987; Demmel and Hagen, 2002) composed of 19 dichotomous items (correct, not correct), e.g. ’Alcohol makes me more talkative’ or ’Sometimes alcohol makes you forget your worries'. The sum score used for statistical analysis showed a high internal consistency of = 0.94.
Statistical analysis
Analysis of differences between consumer groups in terms of the smoking and drinking variables was performed using one-way analyses of variance, followed by planned single comparisons between the concurrent and the respective single substance user groups when appropriate. In case of heterogeneous variances, Welch-Tests were applied. Logistic regression analyses were computed for categorical variables (e.g. daily smoking, ever binge drinking). Differences between consumer groups regarding intrapersonal factors were examined by one-way analyses of variance.
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Results |
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Consumer groups
Of the 326 fifteen-year-olds enrolled in this study, 197 (60.4%) reported lifetime cigarette use and 240 (73.6%) lifetime alcohol use. Rates of lifetime smoking and drinking were similar to data from a recent survey of substance use behaviour in German adolescents (BZgA, 2004
). During the last month, about one third of the adolescents reported consuming alcohol only, 4% were only smoking, about one quarter were concurrent users and approximately 38% neither consumed alcohol nor tobacco (see Fig. 1). The consumer groups did not differ significantly in gender (Chi2 = 6.48, df = 3, P = 0.090) but differed significantly by age (F(3,321) = 9.85, P < 0.000). However, the minor absolute differences (range of group means: 14.82–15.09) became significant just in consequence of the low statistical spread of the age variable. Including age as a covariate did not change the results.
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Tobacco and alcohol consumption
Tables 1 and 2 present descriptive data of the categorical and continuous substance use measures for the different consumer groups. Comparison of adolescents in these groups revealed significant differences in both the smoking and drinking variables. Compared to adolescents who reported drinking alcohol only, concurrent alcohol and tobacco users had a significantly lower age of drinking initiation, higher amounts of alcohol per month and per occasion and were significantly more often drinking alcohol on a weekly basis. Twice as many of the concurrent users than the single alcohol users had ever been drunk or engaged in binge drinking. In contrast to alcohol use, the differences in relation to users of tobacco only were less evident. Compared to the group of single tobacco users, those with concurrent alcohol and tobacco use showed merely higher levels of tobacco dependence. Concurrent alcohol and tobacco users not only drank larger amounts of alcohol and smoked more cigarettes than the reference group, they also were more likely to use cannabis.
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Correlates
When consumer groups were compared with regard to intra-personal risk factors (sensitivity to alcohol and nicotine, novelty seeking, alcohol effect expectancy and tobacco-related self-efficacy and instrumentality), the main effects in Table 3 demonstrate that groups differed in all factors investigated, except for the sensitivity to alcohol. Single contrasts revealed that concurrent users could be distinguished significantly from the users of alcohol only by more positive effect expectancies for alcohol, higher values of novelty seeking, higher self-efficacy and instrumentality expectancies towards tobacco as well as higher sensitivity to the positive effects of nicotine. No significant differences on any of these characteristics, however, were observed between concurrent users and users of tobacco only.
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Discussion |
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This study confirms the strong association between smoking and drinking reported in several surveys of drug use in North American youth in a European sample of 15-year-old adolescents. The prevalence of recent concurrent smoking and drinking of 25% was consistent with epidemiological data from the United States (Anthony and Echeagaray-Wagner, 2000
). According to previous studies with adults and adolescents (Koopmans et al., 1997), the majority of current tobacco smokers also consumed alcohol, whereas only less than half of the current alcohol users also smoked. Hence, the users of tobacco only represented a very small group (4% in our sample).
The results of this study provide further evidence for the fact that adolescents who are consuming both alcohol and cigarettes during the same period exhibit characteristics that are well-known as risk factors for later substance abuse and dependence. Therefore, this group can be considered as a potential risk group for later substance use problems. In particular, our data support the assumption, that concurrent substance use during early adolescence is a risk factor for later alcohol problems. Compared to the users of alcohol only, concurrent substance users started drinking alcohol much earlier with an average of 13 years. The association between early onset of alcohol consumption and higher prevalence rates of alcohol dependence during lifetime has been confirmed by several studies (Grant and Dawson, 1997; DeWit et al., 2000).
Moreover, concurrent users in our study consumed more than three times higher amounts of alcohol on average and displayed higher frequencies of drinking than did users of alcohol only. Most notably, the concurrent users in our sample were characterised by an elevated lifetime prevalence of binge drinking and being drunk. Excessive drinking seemed to be the most prominent difference between users of alcohol only and concurrent alcohol and tobacco users, considering the strong association between excessive drinking patterns and later alcohol abuse and dependence reported by several studies (e.g. Bobo and Husten, 2000). Another risk factor characterizing the concurrent alcohol and tobacco users group was the fact that these adolescents were three to five times more likely to consume cannabis already at the age of 15 than did users of alcohol only or tobacco only. Negative consequences of early onset of cannabis use (before 16 years) such as significantly higher rates of later alcohol abuse and lower psychosocial adjustment have been reported in another longitudinal study (Fergusson and Horwood, 1997).
Differences in smoking parameters between the users of tobacco only and the concurrent users were less pronounced in our study. Even though ex-post power analysis of the contrasts between single tobacco and concurrent users indicated that the lack of statistical significance might be explained to some extent by the small sample size of the former group, the descriptive data do not plead for the existence of differences in the population. According to previous studies (e.g. Griffin et al., 2000; Jackson et al., 2002), concurrent alcohol and tobacco use also leads to higher smoking intensity in late adolescence. This effect might be prepared by the higher level of nicotine dependence exhibited by the concurrent smokers and drinkers in the present study. Further studies are needed to confirm the different effects of double use on the amount of consumed alcohol and tobacco.
Concerning potential correlates of adolescent substance use patterns, concurrent alcohol and tobacco users were characterized by a high load of potential risk factors as compared to the other groups. When the results are considered more in detail, the concurrent user group could be distinguished from users of alcohol only by higher novelty seeking scores and more positive alcohol effect expectancies that are known to increase the risk for substance use in general and for excessive use in particular (Brown et al., 1987; Heath et al., 1995). However, no differences were found between concurrent alcohol and tobacco users and those of tobacco only with respect to tobacco-related characteristics and novelty seeking. Individuals in these two groups demonstrated the same high level of sensitivity to tobacco, high instrumentality and low self-efficacy concerning this substance as well as the same high level of novelty seeking as compared to current non-smokers.
To conclude, the present study strengthens the evidence that even at an early stage of substance use and also in a non-US sample the group of concurrent alcohol and tobacco users can be distinguished from single substance users by higher levels of substance use and misuse as well as by a younger age of initiation. We provide first evidence for the fact that this may only be the case for the comparison between concurrent users and users of alcohol only but not for the comparison with the users of tobacco only. Moreover, this study is the first to characterize the group of concurrent smokers and drinkers with respect to the sensitivity to tobacco and alcohol as well as to the effect expectancies concerning these two substances. All in all, concurrent use of alcohol and tobacco in early adolescence exhibited characteristics that are well known as risk factors for later substance abuse and dependence.
Further research may clarify to what extent concurrent alcohol and tobacco use results from a pharmacological interaction between the two substances and whether it can be explained by a cumulative effect of several intrapersonal risk factors or by an increased vulnerability for substance use in general. The relatively strong associations between intrapersonal characteristics support more the latter interpretation. One limitation of the present study is the fact, that risk factors and substance use were assessed cross-sectionally, so that the direction of possible causal relations could not be determined. Further investigation using longitudinal data is needed to clarify this question.
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