Smoking Cessation and ?
Alcohol Abstinence: ?
What Do the Data Tell Us? ?
Suzy Bird Gulliver, Ph.D.; Barbara W. Kamholz, Ph.D.; and Amy W. Helstrom, Ph.D.
SUZY BIRD GULLIVER, PH.D., is out-
patient mental health site director at the
VA Boston Healthcare System, Brockton
Campus, Brockton, Massachusetts, and
associate professor in the Departments of
Psychiatry and Psychology at Boston
University, Boston, Massachusetts.
BARBARA W. KAMHOLZ, PH.D., is co
director, VA Boston Healthcare System
Mood Disorders Clinic, Jamaica Plain,
Massachusetts, and assistant professor of
Psychiatry and Psychology at Boston Uni
versity, Boston, Massachusetts.
AMY W. HELSTROM, PH.D., is a clinical
psychologist at the VA Boston Healthcare
System and Research Associate at Boston
University, Boston, Massachusetts.
Cigarette smoking and nicotine dependence commonly co-occur with alcohol dependence. However,
treatment for tobacco dependence is not routinely included in alcohol treatment programs, largely
because of concerns that addressing both addictions concurrently would be too difficult for patients and
would adversely affect recovery from alcoholism. To the contrary, research shows that smoking
cessation does not disrupt alcohol abstinence and may actually enhance the likelihood of longer-term
sobriety. Smokers in alcohol treatment or recovery face particular challenges regarding smoking
cessation. Researchers and clinicians should take these circumstances into account when determining
how best to treat these patients’ tobacco dependence. KEY WORDS: Alcohol and tobacco; alcohol,
tobacco, and other drug (ATOD) use, abuse, and dependence; alcohol and other drug (AOD) craving;
AOD use pattern; AOD abstinence; alcohol and tobacco; alcohol abuse; alcoholism; smoking; cigarette
smoking; nicotine; treatment program; co-treatment; treatment outcome; AOD abstinence; cue reactivity;
alcohol and other drug use disorders (AODD) relapse
approximately 80 percent of people
with alcoholism smoke cigarettes and
that most of these smokers are nicotine
dependent (Hughes 1996). Conversely,
smokers are at two to three times
greater risk for alcohol dependence
than nonsmokers (Breslau 1995).
igarette smoking and alcohol
dependence co-occur at high
rates. Research indicates that
Smoking Cessation and
Treatment for Alcoholism
Despite the fact that 60 to 75 percent
of patients in alcoholism treatment are
tobacco dependent and about 40 to 50
percent are heavy smokers (Hughes
1995), treatment for tobacco depen-
dence is not routinely included in
alcohol treatment programs. Smoking
cessation treatment (as well as bans
on smoking) during the course of treat-
ment for alcohol dependence has been
avoided largely out of concern that
concurrently addressing both addic-
tions (or restricting smoking during
treatment for alcoholism) poses too
great a difficulty for the patient and
would adversely affect recovery from
alcoholism. Such concerns are apparent
both in the United States and around
the world (e.g., Walsh et al. 2005;
Zullino et al. 2003). Myths surround-
ing concurrent treatment for smoking
and alcoholism also include the ideas
that smoking is a benign problem rela-
tive to alcoholism, that patients with
comorbid alcoholism have either no
interest or no ability to quit smoking,
and that patients will relapse to alcohol
if they quit smoking. This article
summarizes the scientific findings
that address these issues and provides
evidence-based responses to common
concerns about smoking cessation dur-
ing alcoholism treatment.
Myth: Smoking is more benign than
alcoholism. The short-term effects of
alcoholism may appear more dangerous
Alcohol Research & Health 208
Smoking Cessation and Alcohol Abstinence
than those of cigarette smoking.
However, mortality statistics suggest that
more people with alcoholism die from
smoking-related diseases than from alco
hol-related diseases (Hurt et al. 1996). In
addition, the greater prevalence of smok
ing in alcohol-dependent versus other
populations exacerbates health risks
(Bien and Burge 1990; York and Hirsch
1995). Researchers have demonstrated
synergistic carcinogenic effects for dual
substance dependence. For example, the
relative risk of laryngeal cancer has been
estimated at 2.1 in heavy smokers, 2.2 in
heavy drinkers, and 8.1 in people who
are both heavy drinkers and heavy smok
ers (Hinds et al. 1979).
Myth: Smokers with comorbid alco
holism have either no interest or no
ability to quit smoking. It is interesting
to note that although addiction treatment
programs routinely address multiple
substances of addiction (e.g., alcohol,
marijuana, heroin, cocaine), tobacco is
frequently the sole excluded substance.
The scientific literature also frequently
describes treatment of multiple nonto
bacco substances simultaneously, mak
ing it difficult to evaluate the impact of
smoking cessation on alcoholism treat
ment per se (cf. Prochaska et al. 2004).
Still, evidence contradicts the notion
that smokers with comorbid alcoholism
are not interested in quitting smoking
and that addictions need to be treated
one at a time (e.g., Kalman 1998).
Up to 80 percent of people in addiction
treatment are interested in quitting
smoking (cf. Prochaska et al. 2004).
Consistent with this, Flach and Diener
(2004) found that among dual users,
approximately 75 percent wanted to quit
both smoking and alcohol use (though
the desire to quit alcohol use was rated as
higher). Furthermore, many people
entering treatment for alcoholism are
willing to quit smoking (e.g., Saxon et al.
1997). In fact, one study found that 75
percent of substance-dependent inpa
tients accepted concurrent tobacco treat
ment (Seidner et al. 1996).
Inclusion of smoking as a target for
intervention does not appear to reduce
patients’ commitment to broader addic
tion treatment. For example, incorpo
rating smoking cessation treatment
into inpatient addiction treatment cen
ters has not substantially reduced long-
term treatment completion (e.g., a
minimal drop from 75 to 70 percent at
one site) (Sharp et al. 2003). In addition,
Monti and colleagues (1995) found
that smoking rates actually decrease and
the motivation to quit smoking increases
following successful alcohol treatment.
Evidence suggests that a history of
alcohol use difficulties may not impede
a specific smoking cessation attempt,
though it does seem to reduce the likeli
hood of quitting smoking during one’s
lifetime (Hughes and Kalman 2005).
Research has yet to determine the
extent to which smokers with current
alcohol use difficulties are able to quit
smoking. Though early research has
suggested that quitting smoking would
be more difficult for these patients (e.g.,
Hughes 1996), the answer is now less
clear. The only two studies evaluating
this issue separate from other substances
of abuse and co-occurring psychiatric
disorders yielded mixed findings and
did not include more severe alcohol-
dependent individuals (cf. Hughes and
Kalman 2005). However, studies based
on smokers in substance abuse treat
ment, and those in early recovery, sug
gest that cigarette abstinence is possible,
though challenging (Martin et al. 1997;
Prochaska et al. 2004).
Myths and Data Related to Smoking Cessation
and Alcohol Abstinence
Myth: Smoking is more benign than alcoholism.
• More people with alcoholism die from smoking-related diseases
than from alcohol-related illness (Hurt et al. 1996).
• Comorbid smoking and alcoholism result in synergistic exacerbation of
health risks (Bien and Burge 1990; York and Hirsch 1995; Hinds
et al. 1979).
Myth: Smokers with comorbid alcoholism have either
no interest or no ability to quit smoking.
• The majority (up to 80 percent) of individuals in addiction treatment
are interested in quitting smoking (cf. Prochaska et al. 2004).
• Inclusion of smoking cessation treatment into other addiction pro
grams does not negatively affect rates of treatment completion or
motivation for abstinence (Sharp et al. 2003; Monti et al.1995).
• Alcoholism does not seem to impede specific attempts at quitting
smoking (Hughes and Kalman 2005).
• Alcoholism may make lifetime cigarette abstinence more challenging,
but it remains possible (Martin et al. 1997; Prochaska et al. 2004).
Myth: Smoking cessation will impede successful alcohol use outcomes.
• The majority of research indicates that smoking cessation is unlikely
to compromise alcohol use outcomes (cf. Fogg and Borody 2001).
• Participation in smoking cessation efforts while engaged in other
substance abuse treatment has been associated with a 25 percent
greater likelihood of long-term abstinence from alcohol and other
drugs (Prochaska et al. 2004).
• Data indirectly suggest that continued smoking increases the risk of
alcohol relapse among alcohol-dependent smokers (Taylor et al. 2000).
Vol. 29, No. 3, 2006 209
Myth: Smoking cessation will impede
successful alcohol use outcomes. Perhaps
most important is the concern among
treatment providers (and patients) that
patients must choose between abstinence
from cigarettes and abstinence from
alcohol. In contrast to this concern,
research suggests that treating tobacco
dependence within broader addiction
programs does not adversely influence
recovery from alcoholism (or illicit sub
stances). Although not universal (e.g.,
Joseph et al. 2004), the majority of
findings indicate that smoking cessation
efforts and smoking abstinence are
unlikely to negatively influence alcohol
use outcomes (cf. Fogg and Borody
2001). In a recent meta-analysis,
Prochaska and colleagues (2004) evalu
ated the outcomes of smoking cessation
interventions in 19 randomized con
trolled trials with people in addiction
treatment or recovery. At the end of
treatment, no differences in substance
use outcomes were found between
patients who engaged in smoking cessa
tion treatment and those who did not.
Looking at long-term abstinence from
substances, an even more important
finding emerged. That is, at long-term
follow-up, participation in a smoking
cessation intervention provided during
substance abuse treatment was associ
ated with a 25 percent greater likelihood
of long-term abstinence from alcohol
and other drugs. Consistent with these
findings, data suggest that 1 year after
treatment, smokers who participated in
a substance abuse treatment program
and initiated smoking cessation on their
own were less likely to be diagnosed as
alcohol dependent and had more days
abstinent from alcohol and other sub
stances than those who started or contin
ued smoking during the follow-up
period (Kohn et al. 2003). Thus, empir
ical evidence suggests that smoking ces
sation efforts may result in improved
alcohol-related outcomes (even if those
efforts do not yield substantial smoking
The mechanisms of action responsi
ble for the potential benefits of smok
ing cessation interventions provided
during alcoholism treatment remain
largely unexplored. However, possible
explanatory factors may include greater
clinical contact time, reduced exposure
to substance use cues, relapse prevention
and/or coping skills practice, increased
mastery or self-efficacy, and broader
healthy lifestyle choices (Prochaska et
al. 2004). Self-initiated efforts to reduce
smoking also may reflect increased patient
motivation or lower levels of nicotine
dependence (Karam-Hage et al. 2005).
Alcohol-dependent patients who
quit smoking while in recovery from
alcohol problems also do so without
negative consequences to their alcohol
or drug abstinence (Bien and Burge
1990; Bobo 1989; Hurt et al. 1993;
Irving et al. 1994; Joseph et al. 2003;
Sobell et al. 1990; Sullivan and Covey
2002). Data suggest that among alcohol-
dependent smokers in early recovery,
nicotine deprivation is not associated
with an increased urge to drink. In
addition, among people with signifi
cant alcohol abstinence, evidence sug
gests that smoking cessation does not
increase the likelihood of relapse to
alcohol use or increase alcohol-related
cravings (Hughes et al. 2003). Data
from Project MATCH, the largest alco
holism clinical trial published to date,
indicates that alcohol-dependent smok
ers can quit smoking cigarettes without
putting their sobriety at risk. In fact,
those who quit smoking during their
participation in Project MATCH drank
less than those who did not quit smoking
and significantly reduced their alcohol
intake for the 6 months after quitting
smoking (Friend and Pagano 2005).
Similarly, Karam-Hage and colleagues
(2005) studied smokers in alcohol
treatment and found that participants
who quit smoking on their own were
more likely to report alcohol abstinence
at 1- and 6-months’ followup than
participants who did not quit smoking
(though this may be a function of
lower levels of nicotine dependence).
Not only does the preponderance of
evidence suggest that smoking cessation
does not compromise alcohol abstinence,
but multiple studies indirectly suggest
that continued smoking may place
alcohol-dependent smokers at risk for
alcohol relapse (Taylor et al. 2000).
These data are consistent with laboratory
studies on cross-cue reactivity, which
suggest that nicotine dependence and
alcoholism may interact to increase
drinking risk. For example, alcohol
cues, such as the sight or smell of an
alcoholic beverage, can increase smok
ing urges among smokers with alcohol
use disorders (e.g., Cooney et al. 2003;
Drobes 2002; Gulliver et al. 1995;
Rohsenow et al. 1997), and the degree
of nicotine dependence among alco
holic smokers is positively related to
alcohol cue reactivity (Abrams and
Biener 1992). In addition, a study of
hazardous drinkers (i.e., those scoring 8
or above on the Alcohol Use Disorders
Identification Test [Babor et al. 1992])
found that 6 hours of nicotine depri
vation was associated with increased
alcohol cravings during exposure to
smoking cues (e.g., cigarette lighter,
ashtray, pack of favorite cigarettes) as
well as increased alcohol consumption
during a taste test procedure (Palfai et
al. 2000). Alcohol cravings also were
increased during neutral cue exposure,
suggesting that stopping one drug of
abuse and not another may result in
cross-cue reactivity that places a person
in recovery at increased risk for relapse
(Bobo et al. 1998; Toneatto el al. 1995).
Challenges in Treating
Unfortunately, even with today’s best
interventions for tobacco cessation,
smokers in alcohol treatment or recov
ery face particular challenges to their
cessation efforts. On average, compared
with smokers who do not abuse sub
stances, alcoholic smokers are more
addicted to nicotine, smoke higher
nicotine cigarettes, smoke more per
day, and score higher on nicotine
dependence measures and on carbon
monoxide assessment (Burling and
Burling 2003; York and Hirsch 1995).
Many smokers with alcoholism report
that they use smoking to cope with
their urges to use alcohol or other drugs
(Rohsenow et al. 2005), so alcohol-
dependent smokers may have stronger
views about the benefits of continued
tobacco use than do other smokers.
In addition, nicotine positively influ
ences information processing among
Alcohol Research & Health 210
Smoking Cessation and Alcohol Abstinence
alcoholics (i.e., nicotine use increases
the speed and accuracy of information
processing) (Ceballos et al. 2006),
which may decease motivation to
change. Thus, researchers and clini
cians must take into account the char
acteristics of tobacco dependence in
alcohol-dependent populations when
determining how best to treat these
patients’ tobacco dependence.
Despite concerns to the contrary, the
majority of empirical evidence indi
cates that smoking cessation (whether
through formal treatment or self-initiated
change) does not pose a risk to success
ful alcoholism treatment. Not only does
smoking cessation not disrupt alcohol
abstinence, it actually may enhance the
likelihood of longer-term sobriety.
Although research has yet to determine
the extent to which smoking cessation
is impeded by active alcohol use diffi
culties, the presence of these difficulties
does not prohibit achievement of
tobacco abstinence. Given the substantial
negative health consequences of co
occurring cigarette smoking and alco
holism, smoking cessation efforts in the
context of treatment for alcoholism are
likely to yield important benefits to
patients physically, emotionally, socially,
and economically. ■
This work was supported by the fol
lowing grants: DA016138 awarded to
Barbara W. Kamholz, Ph.D; 1R01–
AA013727 awarded to Domenic Ciraulo,
M.D.; 2R01–AA1164201A awarded to
Dena Davidson, Ph.D.; and the Veterans
Administration Research Enhancement
Award Program (REAP) awarded to
Ronald Goldstein, M.D.
The authors declare that they have no
competing financial interests.
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