Dossier: Influence of alcohol consumption and smoking habits on human health
Smoking and drinking as complementary behaviours

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Abstract

Parallels and contrasts between tobacco smoking and alcohol drinking are considered, in terms of harms, cultural positioning, and a dependence, which is social as well as physical and psychological. Evidence is briefly reviewed of two kinds of conjunction: of being a smoker and being a drinker, and of the smoking event and the drinking event. The complementary relation between smoking and drinking, it is argued, can be understood at physiological, psychological and social levels. Implications for prevention, intervention and policy are discussed, including the need for international agreement on alcohol as well as tobacco control.

Introduction

Nicotine and alcohol, along with caffeine, are the most widely used psychoactive substances. Nicotine and alcohol are also the substances ingested by humans which cause the greatest harm to health. According to the WHO Global Burden of Disease estimates for 2000, tobacco smoking is responsible for 4.1% and alcohol drinking for 4.0% of avoidable disability or loss of life, in terms of net disability-adjusted life-years, or DALYs ([1]; estimated beneficial effects of alcohol have been subtracted out). In low-mortality developed countries, including Europe and North America, e.g. established market economies such as Germany, the estimated proportions of DALYs lost are 12.2% for tobacco and 9.2% for alcohol.

In the case of nicotine, nearly all of the health harm does not come from the psychoactive substance itself, but from what is also ingested in customary modes of use. There are thus modes of use of nicotine, uncommon at present, which carry very little health harm [2]. In the case of alcohol, there are modes of use with essentially no risk to health, and some, in fact, which seem to be beneficial to health. However, a pattern of use of alcohol likely to be beneficial to health but carrying no risk of casualty or other health or social harm is also quite uncommon [3], particularly when a global perspective is taken [4]. This reflects the fact that for alcohol, unlike tobacco, much of the harm is associated with the specific occasion of drinking, and not with enduring patterns of use. Most drinkers engage in at least some risky drinking, and in many developing countries risky patterns are predominant [4].

The fact that much of the potential and immediately recognizable harm from drinking is associated with drinking in the immediate occasion, and the related fact that attention and motor skills are decreased by drinking more than a little, have done much to shape customary patterns of drinking. Both in terms of who may participate and in terms of the nature of the occasion, drinking occasions are enclaved and set apart in many societies. In most places, drinking is forbidden to children, and in many traditional societies it is forbidden to all or most women also. In many developed societies, there was a long struggle in the process of industrialization to remove drinking from the workplace. Most people disapprove of having more than one or two drinks at most when one is caring for children or about to drive a car [5]. Enclaved from everyday life, drinking occasions are defined in many cultures as a “time out” from normal responsibilities, as a time for sociability and relaxation, often somewhat transgressive of the norms of everyday life [6], [7]. The result of the enclaving is a heavy concentration of drinking by time and occasion, so that drinking largely occurs on weekday evenings and weekends [8].

In many cultures, tobacco smoking has also been restricted in terms of who may participate, with children usually excluded, and often women also. But for much of the 20th century, at least in industrialized countries, tobacco smoking was much less enclaved to particular occasions than drinking. In part, this reflected that nicotine is not an immediate impediment to thinking and motor skills, and may even enhance performance in intellectual work. In the 20th century, in many places cigarette smoking became a medium of sociable interaction as well as an individual habit, including sociable interaction in the workplace. Where “having a few drinks” often marks the end of the work week or workday, the sociable cigarette often marked the end of a spell of work. Thus, in the Australia of my childhood, a short collective break from manual work was known as a “smoko”.

Much of the anti-smoking effort in recent years may be seen as an effort to increase the enclaving of tobacco smoking, by limiting the places and circumstances in which cigarette, cigar or pipe smoking can occur. In many places, there has been a long march through social institutions and public spaces in terms of moves to increase smoking restrictions. There were always some places and occasions when smoking would have been unthinkable—at church services, for instance—but in the last 30 years or so the restrictions have been progressively extended, in some countries to cover most indoor public spaces and occasions. It is relevant to the present topic that taverns and other drinking places have often been the last such places to be covered. The resistance to banning smoking in taverns (e.g., [9]) may be seen as a marker of the close association of smoking and drinking.

Prior to the effort to restrict smoking in the workplace and in public spaces, the situation in many countries was that smoking was usually acceptable on occasions where drinking was acceptable, but the reverse was not true—there were many occasions where smoking was acceptable but drinking was not. The increased enclaving of smoking is now probably pushing the two behaviours towards a closer conjunction.

Both nicotine and alcohol are classified as dependence-producing substances; that is, heavy users may find it difficult to cut down or quit their use even if it is seen as problematic. Part of what binds the smoker or drinker to the behaviour is physiological; for instance, that use will forestall or relieve withdrawal symptoms. Another part is psychological; for instance, that the smoking or drinking provides short-term psychological benefits to the smoker or drinker, despite any harm which may ensue. Regular use has provided the smoker or drinker with a set of cues for the behaviour, which can render the behaviour automatic—the smoker may have no consciousness of lighting another cigarette, the drinker of refilling the glass.

A third, and often crucial, part of what binds the smoker or drinker to the behaviour is its social nature. For most drinkers, drinking is quintessentially a part of various forms of sociability. For example, in many societies, it is considered rude to refuse an offer of a drink. In English-speaking societies, “round-buying” customs may dictate that, once the male drinker is included in a “round” of drinks, he is committed to consuming at least as many drinks as the number of people in the drinking group. For many drinkers, drinking becomes strongly involved with courtship and sexuality, so much so that intimacy may seem impossible without drinking. Through such mechanisms, dependence may be conceptualized as being as much a social as a psychological and physiological problem [10].

Smoking has also been very much a sociable behaviour, so that nicotine dependence is social as well as physiological and psychological. Thus, offering cigarettes was until quite recently often a routine part of hospitality. In many circumstances, it would be seen as inexcusably selfish and rude to refuse to share one’s cigarette supply. The offering, lighting and sharing of cigarettes, as much as the minor rituals of drinking, have often been a carrier of cues in courtship and sexuality. The sociable aspect of smoking may be in the process of change, although the clusters of smokers outside the doors of public buildings in Canada and elsewhere signify that prohibitions on smoking at work have changed rather than eliminated the sociable aspects of smoking.

Section snippets

Being a smoker and being a drinker

So far, we have considered the parallels between smoking and drinking as separate behaviours. But in fact they often occur together. The conjunction of smoking and drinking can be seen as occurring at several levels. In the first place, in industrial societies, smokers are more likely than others also to be drinkers, and drinkers also to be smokers. Among US high school seniors, Dee [11] finds a coefficient of 0.41 for current smoking predicting current drinking, controlling for other

Understanding the association

How are we to understand the strong association between smoking and drinking, and particularly between heavy smoking and heavy drinking? The connection is overdetermined—again, we may think in terms of factors at each of the physical, psychological and social levels.

Untangling the connections between smoking and drinking at the physical level seems to be a complex task. Pharmacologically, ethanol and nicotine have effects which partially counteract each other, and users apparently use them to

Implications for prevention, intervention and policy

Given that heavy smoking appears to be a risk factor for heavy drinking, and heavy drinking a risk factor for heavy smoking, what are the implications for prevention, intervention and policy? The controlled trial we have just cited lends weight to the movement in alcohol problems treatment away from the old policy in the field of ignoring smoking, and instead tackling smoking as well as drinking in the treatment program. Reflecting the profile of problems associated with tobacco smoking,

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    Revised from a presentation at the 44th International ICAA Conference on the Prevention and Treatment of Dependencies, Heidelberg, Germany, 2–6 September 2001.

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