Q&A: The Intersection of Drug, Alcohol and Tobacco Use

A new and emerging area of research falls at the intersection of drug, alcohol and tobacco use. This topic is especially relevant to Legacy’s focus on young adults because this age group has the highest documented rates of substance use compared to any other age group. For example, rates of alcohol use disorders in the general population are about 8 percent, but these rates can be double to triple that high in young adults.

Amy Cohn is Research Investigator for Legacy’s Schroeder Institute for Tobacco Research and Policy Studies who is heading and collaborating on more than half a dozen research papers and studies on tobacco’s relationship with drugs, alcohol and other substances. Her work spans monitoring real time patterns of tobacco and alcohol using a telephone survey and measuring people’s thought patterns about smoking and drinking, to studying how products like little cigars, e-cigarettes, or hookah might impact marijuana and alcohol use, and vice versa. Join Together talked to her about her work and how it could change the way we think about how to frame anti-tobacco interventions and educational campaigns.

Why is studying tobacco in the context of other substances important?

Amy Cohn: Tobacco use does not operate in a vacuum. We are finding, particularly among young adults, that tobacco is often used with other substances, like alcohol and marijuana.

Tobacco use is only “the tip of the iceberg” of substance abuse for some young people. For any prevention or intervention to be effective, one needs to address the co-occurrence of these behaviors. For instance, anti-tobacco messages would benefit from focusing on combating tobacco and other drug use together, rather than focusing primarily on tobacco use.

How does this impact youth and young adults?

Amy Cohn: High rates of alcohol and drug use among young adults are associated with a variety of social, emotional, and occupational/academic negative consequences. Echoing the published literature from the alcohol and tobacco fields of research, one of our recent studies showed that young adults between the ages of 21 and 24, who are White non-Hispanic, and who have some college education or greater, have the highest rates of alcohol and drug use relative to other demographic groups.

One reason for this could be that the transition from high school to college particularly marks a time period of significant role change and enhanced personal responsibility. Young adults are often confronted with a variety of life changes such as residential mobility, marriage, increased educational pressure, or full-time employment as well as having to take on a number of life roles, such as student, worker, and/or parent/spouse. Alcohol and other substance use, including tobacco use, may be used experimentally during this time, or may be used as ways to cope with developmental changes. For some people, experimental use becomes habitual, and a problem. We need to understand what factors lead to the “tipping” point from experimentation to regular use. These are the people on which we need to focus our efforts.

In addition to enhanced responsibilities and little to no parental or adult supervision, young adults in college also experience the peer pressure and social environments that encourage substance use experimentation, which is a ubiquitous aspect of weekly life on or off a college or university campus. Anecdotally, when interviewing college-bound young adults about their substance use behavior, if asked how much they use on “weekends”, they typically note a weekend starts on Thursday. So the college atmosphere creates more opportunities to drink and try other drugs than otherwise would be.

What have you learned studying tobacco in relationship to other substances?

Amy Cohn: The deeply entrenched nature of smoking is a challenge. Further, the emerging picture of many different “profiles” of today’s smokers, coupled with the growing popularity of other types of tobacco products (e-cigarettes, hookah) means there is a not a “one size fits all” approach to helping people quit or not start using tobacco at all. We are finding that alcohol and drug use show different relationships to different types of tobacco products. Thus, it is not always the case that EVERY person who drinks, or who reports using marijuana, will show the same risk for using any type of tobacco product. In one recent paper for example, we found that marijuana use appears to be most strongly correlated with little cigars and cigarillo (LCC) use, not cigarette use. Our research is really in its infancy in terms of understanding “who” and “what” impacts risk for tobacco initiation and progression to regular use in young people.

What we do know, however, is that heavier and more frequent users of alcohol and/or other drugs are more likely to persist in their tobacco use, use a variety of tobacco products, have greater levels of nicotine dependence, and, more importantly, are less successful at quitting if they do make a quit attempt.

How or why does using more than one substance impact addiction?

Amy Cohn: There are certain cognitive schemas, or internal scripts that people learn and develop over time that deeply intertwine multiple addictive behaviors together. Learning to smoke, and the contexts surrounding smoking, is similar to driving a car – think about all of the behaviors that you have to coordinate to drive a car? Open the door, sit down, put on seat belt, put foot on brake, turn ignition, put car in drive, etc. Through multiple repetitions over time, these behaviors become deeply ingrained in our script of “how to drive a car,” and they are automatically triggered when we step into a car, even without consciously thinking about them.

It’s the same thing with smoking and the use of other substances, like alcohol. If smoking and drinking occur together more often than not, and their co-use makes the person feel “good,” then this becomes a very powerful and reinforcing script for smoking. This is one reason why smokers who are drinkers have a tougher time quitting.

In one of my grant-funded projects, we are following the smoking behavior of heavy drinking smokers for six months. Most individuals report making changes to their drinking, but few are reducing their cigarette use. This further highlights how difficult it is for these high-risk smokers – those with co-occurring substance abuse – to quit using cigarettes.

If smoking cessation is to be successful, we have to undo a very powerful and deeply engrained script and help smokers learn a whole new script that is just as rewarding to them. This can be an uphill battle.