sign in sign up
<<
Home , Nicotine dependence, Substance dependence

Cessation Treatment for -Dependent Smokers: When Is the Best Time?

Molly Kodl, Ph.D.; Steven S. Fu, M.D., M.S.C.E.; and Anne M. Joseph, M.D., M.P.H.

Cigarette smoking is highly prevalent among people with alcohol use disorders. Although several studies have demonstrated the feasibility of treating dependence in people with substance use disorders, researchers and clinicians continue to debate whether treatment should be delivered simultaneously with or subsequent to alcohol treatment. Evidence suggests that alcohol- dependent individuals prefer sequential treatment and that simultaneous treatment can negatively impact alcohol use outcomes, although the literature is not conclusive. This review includes recommendations of considerations for treatment timing decisions and future research directions. KEY WORDS: Alcohol and tobacco; alcohol and other (AOD) use, abuse, and dependence; smoking; nicotine dependence; treatment; treatment outcomes; concurrent treatment; co-treatment; intervention; cessation of AOD use (AODU)

igarette smoking is highly smoking treatment (Hurt and Patten Substance-Dependent prevalent among people with 2003; Sussman 2002). Theoretical Smokers’ Perspectives on Calcohol abuse and dependence arguments against simultaneous treat- Smoking Cessation (i.e., alcohol use disorders) (Hughes ment include the possibility that con­ 1996). Rates of current smoking range current intervention could be detri- Early studies suggested that a minority from 35 to 44 percent in population- mental to alcohol treatment outcomes of people in treatment for alcohol or based studies of adults with alcohol use (Bowman and Walsh 2003; Joseph et other drug abuse were interested in disorders (Grant et al. 2004; Lasser et al. 2004b; Kalman 1998). Another fre- smoking cessation (Kozlowski et al. al. 2000) and may reach 80 percent in quently cited reason to avoid concur- 1989; Monti et al. 1995; Orleans and treatment-seeking populations (Hughes rent treatment is the belief that alcohol Hutchinson 1993). As national interest 1995). In addition, current alcohol use users do not want to quit smoking in smoking cessation has grown, how- problems are associated with higher (Kalman 1998). This article reviews ever, more smokers in levels of nicotine dependence and a the evidence regarding the effects of treatment are considering quitting lower likelihood of smoking cessation smoking (Ellingstad et al. 1999; (Breslau et al. 1996; Hays et al. 1999). smoking cessation treatment on alcohol Rohsenow et al. 2005). Several studies Given the increased tobacco-related treatment outcomes and the merit of mortality and morbidity in alcohol- simultaneous tobacco treatment versus dependent smokers (Hurt et al. 1996) sequential treatment for alcohol- MOLLY KODL, PH.D., is a fellow; and the enhanced difficulty quitting dependent patients. A detailed review STEVEN S. FU, M.D., M.S.C.E., smoking, identifying the most effective of individual studies is beyond the is an assistant professor of ; treatments and the optimal timing for scope of this article, and we refer read- and ANNE M. JOSEPH, M.D., M.P.H., treatment is critical. ers to Prochaska and colleagues (2004), is a professor of Medicine, all at The Researchers and clinicians continue Hughes and Kalman (2006), Hurt and Center for Chronic Outcomes to debate the advisability of simultaneous Patten (2003), Kalman (1998), and Research at the Minneapolis VA Medical nicotine and treat- Sussman (2002) for comprehensive Center and the University of Minnesota, ment compared with postponing summaries. Minneapolis, Minnesota.

Vol. 29, No. 3, 2006 203 have found that alcohol-dependent studies of sequential treatment. For 1994). Finally, Cornelius and colleagues smokers express a preference for tobacco cessation outcomes among (1999) evaluated the antidepressant flu­ sequential, rather than simultaneous, people with prior alcohol use, see the oxetine versus placebo in the treatment tobacco treatment (Ellingstad et al. Textbox. of 42 depressed, alcohol-dependent 1999; Kozlowski et al. 1989; Monti et smokers in a randomized controlled al. 1995; Orleans and Hutchinson trial. Average cigarette and alcohol con­ 1993; Rohsenow et al. 2005). This Studies of Concurrent sumption both were reduced for those may be especially true for alcohol- Treatment in the treatment group compared with dependent smokers who rely on smok­ the control group (Cornelius et al. ing to help them to cope with urges to Studies on the effectiveness of treat­ 1997, 1999). drink (Sussman 2002). ment for current alcohol use problems In contrast, other studies have Other studies suggest that alcohol- and nicotine dependence demonstrate demonstrated worse substance use out­ dependent smokers are not opposed to variable results. Bobo and colleagues comes following smoking intervention. concurrent smoking cessation treat­ (1996, 1998) conducted two random­ For example, Joseph and colleagues ment. Asher and colleagues (2003) ized1 trials of smoking intervention (1993) compared smokers at a residen­ found that fewer than half of alcohol- among alcoholic smokers. Results tial treatment program (68 percent had dependent smokers believed that quit­ showed that receiving a smoking inter­ alcohol as the first drug of choice) who ting smoking would make it harder to vention did not have a significant detri­ enrolled before or after implementation maintain sobriety, and only 13 percent mental effect on alcohol use (Bobo et of a hospitalwide smoking ban and believed that if they quit smoking, they al. 1996, 1998). However, neither study mandatory smoking cessation interven­ would be unable to manage urges to demonstrated significant intervention tion. At follow-up, averaging 11 to 16 drink or use . Despite this, lack of effects on smoking. Rates of smoking months after treatment, 3 percent of opposition to simultaneous treatment abstinence ranged from 3 to 9 percent those who enrolled prior to the ban may not be synonymous with willing­ for intervention groups and 6 to 7 per­ and 10 percent of those enrolled after ness to participate in concurrent smok­ cent for the control groups at 6- and the ban and who received the smoking ing cessation treatment (Campbell et 12-month follow-up visits (Bobo et al. intervention were abstinent from al. 1998). Overall, individual prefer­ 1996, 1998). In a nonrandomized study (the difference was not signif­ ences regarding treatment timing may of 101 alcoholics receiving inpatient icant). Results suggested that people depend on the degree of relatedness treatment, those who received a 10­ who received the smoking intervention of smoking and drinking behaviors hour group smoking intervention had had worse substance use outcomes than (Ellingstad et al. 1999; Rohsenow et al. higher rates of smoking cessation than those who did not2 (Joseph et al. 1993). 2005; Sobell et al. 1995). For example, those in the control group (11.8 per­ Grant and colleagues (2003) studied Ellingstad and colleagues (1999) found cent versus 0.0 percent) and similar 40 alcohol-dependent veterans in out­ that patients interested in concurrent alcohol and drug use outcomes 1 year patient treatment, half of whom received treatment, compared with those who after treatment discharge (Hurt et al. a 5-week group smoking intervention. preferred to address alcohol dependence Although there were no significant dif­ first, were more likely to believe that ferences in the prevalence of smoking quitting cigarettes would help them to abstinence in the past 7 days at 12 resolve their drinking. Tobacco Cessation months (100 percent of the interven­ tion group and 93 percent of control Outcomes Among People subjects were smoking), results suggested Treatment Outcomes for With Prior Alcohol Use increased drinking in the intervention Alcohol-Dependent group (e.g., at 1 month, 33 percent of Early studies (Bobo et al. 1987; Smokers the intervention group and 0 percent of Covey et al. 1993), more recent the control group reported having more examinations (e.g., Hughes and There are two important issues to con­ than one drink) (Grant et al. 2003). Callas 2003), and an upcoming sider regarding smoking intervention Finally, a recent meta-analysis of 19 comprehensive review (Hughes for alcohol-dependent smokers: effects randomized controlled trials of smok­ and Kalman 2006) do not provide on smoking behavior (i.e., abstinence ing cessation intervention for people in evidence that a history of alcohol from tobacco) and effects on impacts smoking cessation treatment outcomes (i.e., abstinence or 1 Researchers use randomization, or random assignment outcomes. Smokers with past reduction of alcohol use). This section of study participants to intervention and control groups, to alcohol use disorders appear to eliminate bias. will review studies of tobacco cessation be as able to stop smoking as and substance abuse treatment among 2 Among users, those in the intervention group smokers in the general popula­ people with concurrent smoking and had significantly worse outcomes when people who could tion (Hughes and Kalman 2006). not be followed up because they did not respond to substance abuse, first reviewing studies researcher requests for information were categorized as of concurrent treatment, followed by treatment failures (i.e., nonrespondents).

204 Alcohol Research & Health Tobacco Cessation Treatment for Alcohol-Dependent Smokers

treatment for or recovery from an ing treatment had significantly lower in alcohol treatment and did not observe addiction3 concluded that there was alcohol abstinence rates at 6-, 12-, and a detriment to sobriety, these studies no detrimental effect on substance use 18-month follow-up visits (Joseph et al. also had methodological limitations.4 outcomes from combined treatment 2004b). The time to first use of alcohol Greater detriment to alcohol use out­ (Prochaska et al. 2004). Smoking cessa­ was shorter for those in the concurrent comes among those receiving actual tion interventions were not successful versus the delayed group, although the simultaneous smoking and alcohol in achieving long-term smoking absti­ time to was similar and there treatment is consistent with review nence, however, in comparison to the were no significant differences in the findings showing increased smoking control groups (Prochaska et al. 2004). number of drinking days in the past 6 abstinence when tobacco treatment is Prochaska and colleagues’ (2004) review months (Joseph et al. 2004b). delivered following a longer period of suggests, based on studies of individu­ The other randomized trial of smok­ sobriety (Prochaska et al. 2004; als in treatment for or recovering from ing treatment timing followed 36 male Sussman 2002). , that treatment veterans in a residential alcohol treatment for both nicotine and other substance program (Kalman et al. 2001). Smoking dependence is not harmful. In fact, cessation treatment consisting of three Summary and Suggestions although the data regarding the impact 45-minute counseling sessions was for Future Research of continued smoking on maintenance administered either 2 or 6 weeks after of alcohol abstinence are mixed (Sobell admission. At the 20-week follow-up, 19 Research to date suggests that alcohol- et al. 2002), the findings of the Prochaska percent of the concurrent treatment and nicotine-dependent smokers are and colleagues’ (2004) review suggest group and 8 percent of the delayed interested in smoking cessation but that receiving a smoking cessation smoking intervention group (difference prefer to address alcohol dependence intervention while in treatment may not significant) reported smoking absti­ prior to embarking on quitting smoking help with long-term abstinence from nence for the prior 7 days. However, (e.g., Ellingstad et al. 1999). Overall, alcohol and other drugs. other outcome data suggested greater many alcohol-dependent smokers seem rates of relapse to alcohol in the delayed more interested in smoking treatment Studies of Concurrent Versus smoking cessation intervention group after a delay or period of sobriety, which Delayed Treatment. Only two (Kalman et al. 2001). has yet to be adequately quantified by known randomized controlled studies A potential explanation for the dis­ research. Evidence suggests that effec­ have specifically evaluated the effects of crepancy in findings regarding effects tive smoking cessation interventions providing tobacco cessation treatment on alcohol treatment outcomes is the can be delivered but that their success concurrently with alcohol dependence variable timing for delivery of smoking often is short-term and dependent on treatment versus sequential treatment intervention, even among the protocols treatment format (Prochaska et al. 2004). for tobacco and alcohol (Kalman et al. described as concurrent treatment. For Experimental evidence also suggests 2001; Joseph et al. 2004b). The Timing example, some researchers (Joseph et al. potential for detriment to long-term of Alcohol and Smoking Cessation 1993, 2004b; Grant et al. 2003) provided sobriety among alcohol-dependent (TASC) study, which had 499 partici­ smoking intervention early on in sub­ smokers who receive simultaneous pants, 68 percent of whom were male, stance abuse treatment (within 1 to 2 smoking cessation intervention and was a clinical trial designed to compare weeks of treatment entry). In contrast, alcohol treatment (Joseph et al. 2004b). the effectiveness of concurrent versus other studies provided smoking inter­ Although this conclusion is supported delayed (by 6 months) treatment for vention after a brief period of sobriety by a large randomized controlled trial smoking cessation among individuals or had an interval between the onsets of smoking treatment timing, these receiving intensive alcohol dependence of the two treatments. For example, results (Joseph et al. 2004b) were not treatment (Joseph et al. 2003, 2004a). Bobo and colleagues (1996) provided consistent with a recent meta-analysis The smoking intervention included one brief counseling session at least 3 (e.g., Prochaska et al. 2004). behavioral (i.e., a 1-hour, face-to-face weeks after treatment admission. In Potential reasons for the discrepan­ intervention visit plus up to three fol­ another study (Bobo et al. 1998), only cies in the existing literature include low-up visits) and pharmacologic (i.e., one of four smoking cessation counsel­ heterogeneous study designs, including nicotine replacement therapy) compo­ ing sessions took place before discharge nonrandomized studies. Other limita­ nents. Results indicated that although from alcohol treatment; the majority tions include small sample sizes and, in there were no differences in long-term were conducted postdischarge (i.e., at some cases, predominantly male study smoking cessation rates between groups 8, 12, and 16 weeks). There may be (approximately 16 percent of both important differences, in terms of out­ 3 The meta-analysis (Prochaska et al. 2004) included 12 treatment studies, 5 of which focused on patients in alcohol groups were abstinent at 18 months), comes, between initiating smoking treatment, including Bobo et al. 1995, 1998; Cornelius et differences in alcohol use patterns at treatment immediately and waiting several al. 1997, 1999; Grant et al. 2003; and Kalman et al. 2001. follow-up favored delayed treatment weeks. Although Kalman and colleagues 4 One study (Kalman et al. 2001) had limited power to detect (Joseph et al. 2004b). Study partici­ (2001) and Hurt and colleagues (1994) significant differences because of a small sample size, pants who received concurrent smok­ provided concurrent treatment early on and one (Hurt et al. 1994) used a nonrandomized design.

Vol. 29, No. 3, 2006 205 populations (e.g., Cornelius et al. 1999; cessation treatment. These may include recovering alcoholics. Addictive Behaviors Grant et al. 2003; Kalman et al. 2001; investigations of traditional and alter­ 12:209–215, 1987. PMID: 3661273 Prochaska et al. 2004; Sussman 2002). native treatment formats (including BOBO, J.K.; LANDO, H.A.; WALKER, R.D.; AND The variability in the study populations telephone care, integration with 12­ MCILVAIN, H.E. Predictors of tobacco quit attempts among recovering alcoholics. Journal of and settings (e.g., in recovery, outpa­ step programs, and referral to primary Substance Abuse 8:431–443, 1996. PMID: 9058355 tient, residential, alcohol dependent or care providers). Further detailed study other substance dependent), methods of the effects of the timing of treatment BOBO, J.K.; MCILVAIN, H.E.; LANDO, H.A.; ET AL. Effect of smoking cessation counseling on recovery of recruiting smokers (e.g., voluntary is also needed. For example, research is from : Findings from a randomized or mandatory), lack of consistent defi­ needed to compare smoking cessation community intervention trial. 93:877– nitions (e.g., for “in recovery,” concur­ interventions delivered immediately 887, 1998. PMID: 9744123 rent and sequential treatment), partici­ after substance use treatment with BOWMAN, J.A., AND WALSH, R.A. Smoking inter­ pant interest in smoking cessation, and interventions delivered 2, 4, and 8 vention within alcohol and other drug treatment smoking intervention formats (e.g., weeks later, as well as with interven­ services: A selective review with suggestions for ranging from a brief counseling session tions delivered 6 months later. Finally, practical management. Drug and Alcohol Review to 16 weeks of treatment) add to the it is essential to gather additional infor­ 22:73–82, 2003. PMID: 12745361 difficulty of comparing studies. mation about the role that individual BRESLAU, N.; PETERSON, E.; SCHULTZ, L.; ET AL. Many patients in substance use difference variables such as degree of Are smokers with alcohol disorders less likely to treatment or recovery do not receive alcohol or nicotine dependence, coping quit? American Journal of 86:985– concurrent or delayed nicotine depen­ skills, , and gender may play 990, 1996. PMID: 8669523 dence treatment, which is a pressing in alcohol and tobacco cessation. ■ CAMPBELL, B.K.; KRUMENACKER, J.; AND STARK, issue. This should be addressed by M.J. Smoking cessation for clients in chemical dependence treatment. Journal of Substance Abuse incorporating nicotine dependence Treatment 15:313–318, 1998. PMID: 9650139 treatment into aftercare for patients who Author Note are completing substance use treatment. CORNELIUS, J.R.; PERKINS, K.A.; SALLOUM, I.M.; ET AL. Fluoxetine versus placebo to decrease the With this program design, all smokers The views expressed in this article are smoking of depressed alcoholic patients. Journal of leaving treatment would be urged to those of the author(s) and do not nec­ Clinical Psychopharmacology 19:183–184, 1999. participate in combined behavioral and essarily represent the views of the PMID: 10211921 pharmacologic treatment to quit smok­ Department of Veterans Affairs. CORNELIUS, J.R.; SALLOUM, I.M.; EHLER, J.G.; ET ing. Sequential treatment delivery has AL. Fluoxetine in depressed alcoholics: A double- practical limitations, however. For exam­ blind, placebo-controlled trial. Archives of General ple, if smoking cessation is not offered Acknowledgements 54:700–705, 1997. PMID: 9283504 concurrently with alcohol treatment, it COVEY, L.S.; GLASSMAN, A.H.; STETNER, F.; AND may be difficult to interest individuals Dr. Kodl is supported by a VA Health BECKER, J. Effect of history of alcoholism or major in treatment even 4 to 6 weeks later Services Research and Development depression on smoking cessation. American Journal and maintain their participation, as sev­ Service Fellowship and the University of Psychiatry 150:1546–1547, 1993. PMID: 8379564 eral studies have found (Grant et al. 2003; of Minnesota Transdisciplinary Tobacco ELLINGSTAD, T.P.; SOBELL, L.C.; SOBELL, M.B.; ET Kalman et al. 2001; Joseph et al. 2004b). Use Research Center (NIH P50 DA AL. Alcohol abusers who want to quit smoking: Based on the literature to date, it is dif­ 013333). Dr. Fu is supported by a Implications for clinical treatment. Drug & Alcohol Dependence 54:259–265, 1999. PMID: 10372799 ficult to know conclusively that concur­ Research Career Development Award rent treatment should be avoided, but from the VA Health Services Research GRANT, B.F.; HASIN, D.S.; CHOU, S.P.; ET AL. this is a possibility. Concurrent tobacco and Development Service. Nicotine dependence and psychiatric disorders in the United States, results from the national epi­ dependence treatment should not be demiologic survey on alcohol and related condi­ denied, however, if requested by patients. tions. Archives of General Psychiatry 61:1108–1115, Although the health threats of Financial Disclosure 2004. PMID: 15520358 smoking are clear, many unanswered GRANT, K.M.; NORTHRUP, J.H.; AGRAWAL, S.; ET questions remain about how to best The authors declare that they have no AL. Smoking cessation in outpatient alcohol treat­ approach smoking cessation in alcohol- competing financial interests. ment. Addictive Disorders and Their Treatment and substance-dependent populations. 2:41–46, 2003. In particular, research based on statisti­ HAYS, J.T.; SCHROEDER, D.R.; CROGHAN, I.T.; ET cally strong randomized controlled trials References AL. Response to nicotine dependence treatment in of fully integrated alcohol and tobacco smokers with current and past alcohol problems. treatment and conducted in diverse ASHER, M.K.; MARTIN, R.A.; ROHSENOW, D.J.; ET Annals of Behavioral Medicine 21:244–250, 1999. AL. Perceived barriers to quitting smoking among PMID: 10626032 samples is needed. We need additional alcohol dependence patients in treatment. Journal data on the most effective smoking of Substance Abuse Treatment 24:169–174, 2003. HUGHES, J.R. Clinical implications of the associa­ treatment modalities for this popula­ PMID: 12745034 tion between smoking and alcoholism. In: Fertig, J.B; and Allen, J.P., eds. Alcohol and Tobacco: From tion and on techniques for orchestrat­ BOBO, J.K.; GILCHRIST, L.D.; SCHILLING, R.F, II; Basic Science to Clinical Practice. NIAAA Research ing the delivery of sequential smoking ET AL. Cigarette smoking cessation attempts by Monograph 30. Bethesda, MD: National Institute

206 Alcohol Research & Health Tobacco Cessation Treatment for Alcohol-Dependent Smokers

on Alcohol Abuse and Alcoholism, 1995. pp. use patients screened and enrolled in a clinical trial. treatment strategies, and policy. In: Fertig, J.B.; and 171–185. Journal of Addictive 22:87–107, 2003. Allen, J.P., eds. Alcohol and Tobacco: From Basic PMID: 14723480 Science to Clinical Practice. Washington, DC: U.S. HUGHES, J.R. Treating smokers with current or Government Printing Office, NIAAA Research past alcohol dependence. American Journal of JOSEPH, A.M.; NICHOL, K.L.; AND ANDERSON, H. Monograph No. 30, 1995. pp. 187–206. Health Behavior 20:286–290, 1996. Effect of treatment for nicotine dependence on alcohol and drug treatment outcomes. Addictive ORLEANS, C.T., AND HUTCHINSON, D. Tailoring HUGHES, J.R., AND CALLAS, P.W. Past alcohol Behaviors 18:635–644, 1993. PMID: 8178702 problems do not predict worse smoking cessation nicotine addiction treatments for chemical depen­ dency patients. outcomes. Drug & Alcohol Dependence 71:269– JOSEPH, A.M.; WILLENBRING, M.L.; NUGENT, Journal of Substance Abuse 273, 2003. S.M.; AND NELSON, D.B. A randomized trial of Treatment 10:197–208, 1993. PMID: 8389897 concurrent versus delayed smoking intervention for PROCHASKA, J.J.; DELUCCHI, K.; AND HALL, S.M. HUGHES, J.R., AND KALMAN, D. Do smokers with patients in alcohol dependence treatment. Journal A meta-analysis of smoking cessation interventions alcohol problems have more difficulty quitting? of Studies on Alcohol 65:681–691, 2004b. PMID: with individuals in substance abuse treatment or Drug & Alcohol Dependence 82:91–102, 2006. 15700504 PMID: 16188401 recovery. Journal of Consulting and Clinical KALMAN, D. Smoking cessation treatment for sub­ 72:1144–1156, 2004. PMID: 15612860 HURT, R.D.; EBERMAN, K.M.; CROGHAN, I.T.; ET stance misusers in early recovery: A review of the AL. Nicotine dependence treatment during inpatient literature and recommendations for practice. ROHSENOW, D.J.; COLBY, S.M.; MARTIN, R.A.; treatment for other : A prospective inter­ Substance Use & Misuse 33:2021–2047, 1998. AND MONTI, P.M. Nicotine and other substance vention trial. Alcoholism: Clinical and Experimental PMID: 9744841 interaction expectancies questionnaire: Relationship Research 18:867–872, 1994. PMID: 7978097 of expectancies to substance use. Addictive Behaviors KALMAN, D.; HAYES, K.; COLBY, S.M.; ET AL. 30:629–641, 2005. PMID: 15833569 HURT, R.D.; OFFORD, K.P.; CROGHAN, I.T.; ET Concurrent versus delayed smoking cessation treat­ AL. Mortality following inpatient addictions treat­ ment for persons in early alcohol recovery: A pilot SOBELL, L.C.; SOBELL, M.B.; AND AGRAWAL, S. ment: Role of tobacco use in a community-based study. Journal of Substance Abuse Treatment Self-change and dual recoveries among individuals cohort. JAMA 275:1097–1103, 1996. PMID: 20:233–238, 2001. PMID: 11516593 with alcohol and tobacco problems: Current 8601929 knowledge and future directions. Alcoholism: KOZLOWSKI, L.T.; SKINNER, W.; KENT, C.; AND Clinical and Experimental Research 26:1936–1938, HURT, R.D., AND PATTEN, C.A. Treatment of tobacco POPE, M.A. Prospects for smoking treatments in 2002. PMID: 12500127 dependence in alcoholics. In: Galanter, M., ed. Recent individuals seeking treatment for alcohol and other Developments in Alcoholism. Vol 16. New York: drug problems. Addictive Behaviors 14:273–278, SOBELL, M.B.; SOBELL, L.C.; AND KOZLOWKSKI, L.T. Kluwer, 2003. pp. 335–359. PMID: 12638645 1989. PMID: 2750568 Dual recoveries from alcohol and smoking problems. JOSEPH, A.; LEXAU, B.; WILLENBRING, M.; ET AL. LASSER, K.; BOYD, J.W.; WOOLHANDLER, S.; ET AL. In: Fertig, J.B.; and Allen, J.P., eds. Alcohol and Factors associated with readiness to stop smoking Smoking and mental illness: A population-based Tobacco: From Basic Science to Clinical Practice. among patients in treatment for alcohol use disor­ prevalence study. Journal of the American Medical NIAAA Research Monograph 30. Bethesda, MD: der. The American Journal on Addictions 13:405– Association: JAMA 284:2606–2610, 2000. PMID: National Institute on Alcohol Abuse and Alcoholism, 417. 2004a. PMID: 15370939 11086367 1995. pp. 207–224.

JOSEPH, A.M.; NELSON, D.B.; NUGENT, S.M.; AND MONTI, P.M.; ROHSENOW, D.J.; COLBY, S.M.; SUSSMAN, S. Smoking cessation among persons in WILLENBRING, M.L. Timing of alcohol and smok­ AND ABRAMS, D.B. Smoking among alcoholics dur­ recovery. Substance Use & Misuse 37:1275–1298, ing cessation (TASC): Smoking among substance ing and after treatment: Implications for models, 2002. PMID: 12180567

Vol. 29, No. 3, 2006 207