Table 3.

Selected studies of innovative approaches to smoking cessation treatment with relevance to smokers in alcohol recovery.

Study	Participants and Design	Intervention	Findings
A. Studies of interventions to enhance motivation to quit smoking among alcoholic smokers
Bobo et al. (1998)	12 SUD residential treatment programs were randomized to either a tobacco cessation or control condition. 575 smokers participated.	Four 10–15 minute counseling sessions tailored to motivational readiness to quit. The first session occurred during subject's residential stay. Remaining sessions occurred 8, 12 and 16 weeks after discharge.	No significant effects of intervention on tobacco quit attempts or tobacco abstinence at one-, six-, or twelve-month follow up. At 12-month follow up, the quit attempt rate was 54% vs. 49% and the tobacco abstinence rate was 9% and 7% in the intervention and control groups, respectively. Only 31% of subjects in the intervention condition received all four counseling sessions.
Rohsenow et al. (2005)	126 subjects in SUD residential treatment were randomized to (1) one session of brief advice (10 minutes); (2) three sessions of brief advice; (3) one session of motivational enhancement (50 minutes; (4) three sessions of motivational enhancement. In conditions two and four, the additional sessions (15 minutes each) were scheduled one and four weeks after the initial session.	Brief advice consisted of direct advice to quit smoking with referral for treatment. Motivational enhancement consisted of exploring pros and cons of smoking, imagining life without smoking, providing personalized feedback and setting stage-specific goals; referral for treatment was also offered.	Smoking abstinent rates were higher in the brief advice conditions at one- and six-month follow up. At six months, the rates for subjects in conditions one and three were 13% and 2% (p < .08), respectively. Only 49% of subjects in the conditions two and four received all three sessions.
B. Pharmacological studies of smoking cessation treatment
Kalman et al. (2006)	130 smokers in residential SUD treatment (103 with between two and twelve months of alcohol abstinence at enrollment) participated in a randomized, double-blind, placebo-controlled clinical trial.	Subjects received either 21-mg or 42-mg transdermal nicotine. Treatment was provided for eight weeks. All subjects also received counseling.	Among the subgroup of subjects with two to twelve months of abstinence, smoking abstinence rates at 36-week follow up in the 21-mg and 42-mg conditions were 11% and 9%, respectively (difference not significant).
Johnson et al. (2005)	94 smokers with alcohol problems participated in a randomized, double-blind, placebo-controlled clinical trial. Note that the study was part of a larger investigation of the efficacy of topiramate for alcohol dependence and subjects did not have to express a readiness to quit smoking to enroll.	Subjects received either placebo or an escalating dose of topiramate (maximum dose = 300 mg per day). Treatment was provided for twelve weeks.	Smoking cessation rates in the topiramate and placebo conditions were 17% vs. 7%, respectively, at the end of 12 weeks (p=.04).
Ebbert et al. (2009)	239 smokers participated in a quasi-experimental study of smoking cessation treatment Study did not enroll smokers with recent alcohol problems.	Subjects received either nicotine replacement (historical controls) or 21-mgs of nicotine replacement plus varenicline (experimental group).	At six-month follow up, smoking cessation rates for subjects in the nicotine replacement plus varenicline and nicotine replacement only condition were 54% and 59%, respectively (difference not significant).
O'Malley et al. (2006)	400 smokers who smoked at least 20 cigarettes per day participated in a randomized, double-blind, placebo- controlled clinical trial. Study did not enroll smokers with recent alcohol problems.	Subjects received either 21-mg transdermal nicotine plus either 0, 25, 50 or 100 mg per day of naltrexone. Treatment was provided for six weeks. All subjects also received counseling.	There was a trend favoring subjects assigned to the 100-mg naltrexone vs. placebo condition at the end of treatment (52% vs. 39%, respectively) in the intent- to-treat analysis. Among treatment completers, the quit rates among smokers in the 100- mg vs. placebo conditions were 72% and 48%, respectively (p=.004). Lower naltrexone doses had little effect compared to placebo.
Byars et al. (2005)	44 female smokers participated in a randomized, double-blind, placebo- controlled clinical trial. Study did not enroll smokers with recent alcohol problems.	Subjects received 21 mg transdermal nicotine plus either 0 or 50 mg per day of naltrexone for 12 weeks. All subjects also received counseling.	Analyses were reported for treatment completers only (n = 12 in each condition). Continuous abstinence rates at end of treatment were 92% and 50% in the naltrexone and placebo conditions, respectively (p=.029).
Krishnan-Sarin (2003)	32 smokers who smoked 20– 30 cigarettes per day participated in a randomized, double-blind, placebo- controlled clinical trial. Study did not enroll smokers with recent alcohol problems.	Subjects received either 21-mg transdermal nicotine plus either 0- or 50-mg per day of naltrexone. Treatment was provided for four weeks.	Continuous abstinence rates during the final two weeks of the study were 56% and 31%, respectively, in the naltrexone and placebo conditions (significance level not reported because of small sample).
Lerman et al. (2004)	216 smokers participated in a randomized, double-blind, placebo-controlled clinical trial. Study investigated the moderating role of a functional variant of the mu- opioid receptor on the efficacy of trandermal nicotine vs. nicotine nasal spray. Study did not enroll smokers with recent alcohol problems.	Subjects received either transdermal nicotine or nicotine nasal spray.	There was a significant effect of genotype on abstinence at the end of treatment in the transdermal nicotine group (52% vs. 33%; p=.02) but no significant effect in the nasal spray group (29% vs. 30%). The effect of genotype on abstinence at follow up was not significant.
Biberman et al. (2003)	109 smokers participated in a randomized, double-blind, placebo-controlled clinical trial. Study did not enroll smokers with recent alcohol problems.	Subjects received either 10-mg selegiline plus nicotine patch or placebo plus nicotine patch. Selegiline and placebo were administered for 26 weeks. The nicotine patch was administered for 8 weeks.	Continuous abstinence rates at one-year follow up in the selegiline and placebo groups were 25% vs. 11%, respectively (p=.08).
Cornuz et al. (2008)	229 smokers participated in a randomized, double-blind, placebo-controlled clinical trial. Study did not enroll smokers with recent alcohol problems.	Subjects received five monthly injections of a nicotine vaccine or placebo.	At 6-month follow up, continuous abstinence rates in the nicotine and placebo groups were 40.3% and 31.3% (not significant). A significant difference in abstinence rates was found for subjects in the active medication group with the highest antibody levels vs. subjects in the placebo group (57% vs. 31%, respectively; p=.004).
C. Studies of behavioral interventions for smoking cessation with smokers in SUD programs
Burling et al (2001)	150 smokers in residential SUD treatment participated in a randomized clinical trial.	Subjects received either (1) a multicomponent smoking treatment (MST) focused exclusively on smoking cessation; (2) a multicomponent treatment plus generalization (MST +G) that used the smoking cessation experience as an opportunity for “generalization training” from cigarettes to alcohol, i.e., participants examined the similarities between successfully quitting smoking and AOD use; (3) a no treatment control (residents who refused smoking cessation treatment). The smoking cessation intervention in conditions one and two occurred several times per week for nine weeks.	At one-month follow up, the smoking cessation rates in the MST and MST+G conditions were 40% and 27%, respectively. At 12-month follow up, the rates in the MST and MST+G conditions were 19% and 13%, respectively.
Joseph et al. (2004)	499 smokers in residential and day SUD treatment programs participated in a randomized clinical trial.	Subjects were randomly assigned to receive smoking cessation treatment during alcohol treatment (concurrent condition) or six months following treatment (delayed condition)	At 18-month follow up, smoking cessation rates in the concurrent and delayed treatment conditions were 12% and 14%, respectively (difference not significant).
D. Organizational change study of smoking cessation treatment in SUD programs
Guydish et al. (2009)	Assessments of an organizational change model (ATTOC) designed to promote the integration of tobacco dependence treatment into substance abuse treatment were conducted prior to and following its implementation in 3 residential SUD treatment programs.	The intervention consisted of several consultations over a period of six months which are designed to help administrative and clinical staff in SUD programs to develop tobacco use policies and clinical practices consistent with the principle that tobacco dependence treatment is central to the mission of SUD treatment	Statistically significant pre- to post-test changes were found on several measures, including staff beliefs about providing smoking cessation services improved (p = .0002), counselor self-efficacy in addressing tobacco dependence with clients (p=.0004), and smoking-related practices used by counselors (p=.0033). Residents also reported significant increases in the amount of nicotine dependence services received (p<.0001), and more favorable attitudes about smoking cessation during addiction treatment (p<.0001).

Note. Several but not all studies in this table investigated innovative approaches to smoking cessation treatment. Study samples are described under "Participants and Design." ATTOC = Addressing tobacco treatment through organziation change. SUD = substance use disorder.

¹Cotinine is a metabolite of nicotine and has a longer half-life than nicotine.