Should you quit drinking and smoking at the same time? What research shows

People being treated for alcohol dependence are often told it is better to put off quitting smoking, because giving up two substances at the same time will put their sobriety at risk. Most studies do not confirm this. In a meta-analysis of 19 studies, help with quitting smoking provided during addiction treatment was associated with a greater chance of long-term abstinence from alcohol and drugs (1), and in a 2016 Cochrane review, such help did not change the proportion of people who stayed abstinent from alcohol and drugs (2).

For these people, smoking itself is also a major threat. At the Mayo Clinic in the US, researchers followed 845 residents of Olmsted County, Minnesota, who had received inpatient treatment in 1972-1983, mainly for alcoholism. Among the 214 who had died by 1994 and whose cause of death was established, 50.9% died of tobacco-related causes and 34.1% of alcohol-related causes (3). When it is best to quit smoking and which medicine to choose depends on the stage of alcoholism treatment.

In brief

• In two reviews of studies involving people in addiction treatment or staying abstinent, help with quitting smoking did not reduce the proportion of people who were not drinking. In the older of the two, from 2004, even more people stayed abstinent.
• In one large 2004 study, people who quit smoking during intensive addiction treatment were less likely to stay abstinent from alcohol than those who quit six months later. The timing of quitting smoking therefore needs to be agreed with a therapist.
• In people who had stopped drinking, continuing to smoke was associated with more frequent relapse to alcohol dependence within 3 years. This is an observational finding and does not prove that smoking causes relapse.
• Clinical data on significant interactions between cytisine and medicines used to treat alcoholism are lacking, so all the medicines you take need to be discussed with a doctor before the course. Bupropion is not used in people who abruptly stop drinking alcohol during treatment.

Does quitting smoking put abstinence from alcohol at risk?

Studies of people being treated for alcohol dependence or staying abstinent do not confirm that quitting smoking threatens sobriety. In reviews of multiple studies, help with quitting smoking did not reduce the proportion of people who were not drinking, and in some analyses this proportion was higher.

What a 2004 meta-analysis found about quitting smoking during addiction treatment

Judith Prochaska's team at the University of California gathered 19 randomised trials in which people in or after addiction treatment received help with quitting smoking. Immediately after the programmes ended, there were more non-smokers than in the comparison groups, but after at least six months this difference was no longer significant. According to the authors, help with quitting smoking provided during addiction treatment was associated with a 25% higher likelihood of long-term abstinence from alcohol and drugs. The researchers concluded that, contrary to earlier concerns, quitting smoking during treatment tended to support sobriety rather than threaten it (1).

What a 2016 Cochrane review found about quitting smoking in recovery

The 2016 Cochrane review included 35 studies involving 5,796 people in or after treatment for alcohol or drug dependence. In groups where participants received stop-smoking medication, the proportion of non-smokers was about 60% higher than in the comparison groups, and in groups where medication was combined with counselling, it was about 74% higher. Counselling alone did not significantly change the results. The proportion of non-smokers also increased among people who had completed treatment and among people dependent on alcohol.

In 11 studies that also looked at drinking and drug use, a similar proportion of people stayed abstinent in the groups with and without help to quit smoking. The authors rated the evidence from the whole review as low quality, mainly because many studies were not described in detail and the support programmes varied greatly (2).

Does continuing to smoke in recovery increase the risk of drinking again?

In observational studies, people who continued to smoke in recovery relapsed to alcohol dependence more often. Such studies show an association, but they do not prove that smoking caused the relapse.

The US NESARC survey analysed data from 9,134 adults who had not met the criteria for alcohol abuse or dependence for at least a year. After 3 years, people who smoked daily were more likely than non-smokers to relapse to alcohol dependence (odds ratio 1.54). The result held after accounting for depression, anxiety disorders, other addictions and the severity of past drinking (4).

The St PETER study in St Petersburg involved 400 smokers with HIV who drank heavily. After 3 months, 35.3% of those who had quit smoking and 17.1% of those who continued to smoke were not drinking. However, this was an additional analysis that had not been planned at the start of the study (5). None of these studies suggests that continuing to smoke helps people stay abstinent from alcohol.

Should you give up alcohol and cigarettes at the same time or one first?

There is no single order for giving up alcohol and cigarettes that suits everyone. Research gives no reason to put off quitting smoking without setting a date, but in one large study, participants in intensive addiction treatment were more likely to stay abstinent if they waited six months before quitting smoking. The timing is best agreed with an addiction therapist and a doctor.

Which study linked quitting smoking with more frequent drinking?

A 2004 US study by Anne Joseph et al. included 499 smokers undergoing intensive treatment for alcohol dependence. Half started quitting smoking straight away, during treatment, and the other half started six months later. In both groups, participants talked to a therapist and used nicotine replacement therapy. After 18 months, the proportion of non-smokers was similar: 12.4% in the group that quit straight away and 13.7% in the group that quit later.

The difference concerned abstinence from alcohol. Throughout the first six months, 41% of those who quit smoking straight away and 56% of those in the delayed group did not drink. After 18 months, the difference in the proportion of people who had not drunk in the previous six months narrowed (41% versus 48%) and was no longer statistically significant. The authors themselves noted that the result differs from other studies and needs to be confirmed (6).

Putting off quitting smoking also has a drawback: some people never make an attempt at all. In the study by Joseph et al., 78.5% of people in the immediate group and 64.5% in the delayed group took up the help on offer. In a small study of 36 men receiving inpatient treatment for alcoholism, fewer people started quitting smoking when the date was set for the sixth week of treatment than when it was set for the second (7).

When should you quit smoking straight away, and when later?

When choosing when to quit smoking, you need to take into account the stage of alcoholism treatment, contraindications to medicines and the preferences of the person quitting. The guidance below does not replace a consultation with a doctor and therapist.

Why is it easy to turn to the other substance after giving up alcohol or nicotine?

Drinking alcohol increases the desire for a cigarette, and smoking increases the desire for alcohol. That is why, after giving up one substance, it is easy to start reaching for the other more often instead of riding out the withdrawal symptoms.

The authors of the NESARC analysis cite earlier studies: after smoking a cigarette, adults reported a stronger desire for alcohol, and using both substances together intensified cravings for each of them (4).

After quitting smoking, you should not ease irritability or restlessness with alcohol. Conversely, someone who has stopped drinking may start smoking more or turn to e-cigarettes or nicotine pouches. Alcohol does not make nicotine withdrawal easier. Irritability, restlessness and insomnia after quitting smoking are strongest in the first week and usually ease within 2-4 weeks (9), and after drinking alcohol it is easier to light a cigarette. Someone dependent on alcohol who drinks to calm down after giving up cigarettes breaks their abstinence.

E-cigarettes and pouches do not remove the dependence; they only change the source of nicotine. We describe how to stop using them in our articles on quitting e-cigarettes and giving up nicotine pouches.

Which stop-smoking medicines are used during alcoholism treatment?

People being treated for alcoholism use the same stop-smoking medicines as other smokers. In a study of smokers with HIV who drank heavily, cytisine and nicotine replacement therapy were similarly effective. When using bupropion and varenicline, the warnings about alcohol need to be taken into account.

Cytisine during alcoholism treatment

Cytisine, the active substance in Desmoxan, Tabex and Recigar, helped people quit smoking in the St PETER study to a similar extent as nicotine replacement therapy. After six months, 19.0% of those taking cytisine and 18.8% of those using a patch or another form of nicotine replacement therapy were not smoking. After 3 months, the number of heavy drinking days had fallen in all groups, and the groups did not differ in this respect. All participants also talked to a counsellor about drinking and smoking (5).

Cytisine should not be combined with tuberculosis medicines, and clinical data on significant interactions with other medicines are lacking (10). A lack of data does not prove that a combination is safe, so before the course, the doctor must know all the medicines you take, including those used to treat alcoholism. Cytisine is not used in unstable angina, after a recent heart attack or stroke, in clinically significant heart rhythm disorders, or during pregnancy and breastfeeding. Caution is also needed in people who have or have had a mental illness, because quitting smoking can make depression, for example, worse. We explain whether you can drink during the course in our article on cytisine and alcohol.

Nicotine replacement therapy with an Esperal implant or disulfiram

Some nicotine gums and mouth sprays contain a small amount of ethanol as an excipient. Nicorette Classic Gum 2 mg contains 0.616 mg of ethanol per piece of gum, and Nicorette Spray about 7 mg per dose, which is less than in 2 ml of beer. Such a small amount of alcohol has no noticeable effects. One 24-hour nicotine patch and one nicotine lozenge do not list ethanol among their ingredients.

When taking Anticol, a disulfiram medicine, caution is needed even with products containing small amounts of alcohol, because they can trigger a disulfiram-alcohol reaction. Someone with an implant or taking disulfiram tablets should therefore choose the form of nicotine replacement therapy together with a doctor or pharmacist.

Bupropion and varenicline in alcohol dependence

Bupropion (Zyban) is contraindicated in people who abruptly stop drinking alcohol at any stage of treatment. Alcohol dependence is one of the factors that increase the risk of seizures, and during treatment with bupropion, alcohol should be avoided or kept to a minimum (11).

In a small study of 33 smokers who misused or were dependent on alcohol, 43.8% of those taking varenicline and 5.9% of those taking placebo were not smoking after 12 weeks (12). Stronger intoxicating effects of alcohol have been reported in people taking varenicline, although a link with the medicine has not been shown (13).

Disulfiram, naltrexone, acamprosate and stop-smoking medicines

You should not assume that every combination of cytisine or nicotine with Anticol (disulfiram), Naltex (naltrexone) or Campral (acamprosate) has been tested in studies. The doctor prescribing a stop-smoking medicine should know about the medicines used to treat your alcoholism, and the doctor in charge of pharmacotherapy for alcoholism should know about your plan to quit smoking.

Tobacco smoke also speeds up the breakdown of theophylline and clozapine, among others, so their blood levels may rise after quitting smoking (10).

How do you plan to quit smoking in recovery?

Quitting smoking during recovery is easier to plan when the addiction therapist and doctor know the date, and the person quitting knows what to do in situations where they used to drink and smoke.

1. The date. Agree a quit date with your addiction therapist so that it does not fall during alcohol withdrawal or an acute crisis. If quitting smoking is to happen later, it is better to write down a specific date straight away.
2. The medicine. The doctor chooses the stop-smoking medicine, taking into account the medicines you take, other conditions and the stage of alcoholism treatment. During the medical interview, you need to give the date of your Esperal implant, if you have had one.
3. Situations linked to drinking and smoking. It helps to write down the places and times when you smoked and drank, such as weekend evenings or meeting friends, and to avoid such situations in the first weeks (8). We write more about such situations in our article on alcohol triggers.
4. Smoking a cigarette again. Smoking a cigarette does not mean going back to drinking. We describe a plan for the first hours after smoking again in our article what to do if you smoke after quitting. If you have alcohol cravings, talk to your therapist straight away. We describe the warning signs of relapse in our article on relapse in alcohol dependence.

Once the decision to quit smoking has been made, the medicine needs to be chosen with alcoholism treatment and other conditions in mind. The nicotine dependence treatment plan at Nasz Gabinet lasts 3 months and starts with a medical interview, after which the doctor chooses the medicine and issues an e-prescription. The module in the app reminds you to take your doses, counts your smoke-free days and lets you keep a diary, and a session with a psychologist can be booked for an additional fee. Someone who drinks and smokes but is not yet being treated for alcohol dependence should start with a consultation about alcoholism treatment, because the timing of quitting smoking depends on it.

When does quitting drinking and smoking need urgent medical help?

Symptoms of severe withdrawal syndrome, drinking alcohol with an implant or while taking disulfiram, and suicidal thoughts need urgent medical help.

• Alcohol withdrawal. Shaking hands, sweating, nausea, restlessness and insomnia after stopping drinking are symptoms of withdrawal syndrome. Seizures, hallucinations or confusion need immediate medical help. We describe the first days in our article on alcohol withdrawal.
• Alcohol with disulfiram. Drinking alcohol with an implant or while taking Anticol triggers a disulfiram-alcohol reaction. Its symptoms can be severe and life-threatening, such as a drop in blood pressure, chest pain, heart rhythm disturbances or seizures. After drinking alcohol, you need to contact a doctor urgently.
• Mood. Low mood can be a symptom of nicotine withdrawal, and in rare cases it is accompanied by suicidal thoughts or suicide attempts. Such thoughts require immediate contact with a doctor or psychiatrist.

This article does not replace a medical consultation.

Frequently asked questions

Can you quit drinking and smoking at the same time?

You can quit drinking and smoking at the same time. Most studies of people being treated for alcohol dependence have not shown that this reduces the chances of staying abstinent, although in one large study, participants in intensive addiction treatment did better at staying abstinent when they waited six months before quitting smoking. Agree the timing with your therapist and doctor; after a drinking binge, a safe detox is needed first.

Can you go back to drinking alcohol after quitting smoking?

After quitting smoking, someone in recovery should not go back to drinking. Going back to alcohol breaks abstinence, and after drinking it is also easier to light up. For people without an alcohol problem, the NCI advises drinking less alcohol or none at all in the first weeks after quitting smoking, choosing drinks other than those you used to have with a cigarette, and avoiding places where you used to drink.

Can you take cytisine with an alcohol implant?

The decision about a course of cytisine with an implant is made by a doctor after a medical interview, during which you need to give the date of the implant and all the medicines you take. Clinical data on significant interactions between cytisine and disulfiram, the substance in the implant, or other medicines used to treat alcoholism are lacking. A lack of such data does not prove that the combination is safe.

Can e-cigarettes replace cigarettes in recovery?

E-cigarettes do not remove nicotine dependence; they only change its source. In a 2023 Cochrane review, nicotine e-cigarettes helped people stop smoking tobacco cigarettes, but in these studies someone who stopped smoking cigarettes did not have to stop using nicotine (14). Someone who started using e-cigarettes after giving up alcohol can plan to stop using them together with a therapist, in the same way as quitting cigarettes.

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