Continued research is clearly needed to investigate the efficacy of integrated models on tobacco and other drug use outcomes. As noted above, findings from Burling et al. (2001)
suggest that higher smoking abstinence rates are achieved when smoking cessation treatment is provided in an SUD program that has integrated this service. However, a clinical trial is needed to determine whether a sustained, higher-intensity intervention in the context of integrated treatment produces significantly better outcomes (e.g., more people attempting to quit smoking concurrently with alcohol treatment, higher smoking abstinence rates) than the unintegrated, lower-intensity treatment that have often characterized clinical trials to date with this population.
Research should also investigate the efficacy of a chronic care model of treatment in this population. According to the chronic disease model, for many smokers, and especially highly dependent smokers, tobacco dependence is a chronic medical condition that is best treated in the same manner as other long-term, chronically relapsing conditions such as alcohol dependence, depression and diabetes (Steinberg, Schmelzer, Richardson & Foulds, 2008
). These smokers should be offered long-term treatment, including extended use of pharmacotherapy, rather than episodic treatment. Hall, Humfleet, Reus, Munoz and Cullen (2004)
provided evidence that extended treatments that combine medication and psychological interventions can produce abstinence rates that are substantially higher than those in the literature. In their study, one-year abstinence rates for participants who were assigned to extended treatment (which consisted of 52 weeks of medication use and 14 concurrent counseling sessions) vs. eight weeks of treatment were 50% and 30%, respectively (see also Hays et al., 2001
). Support for long-term care models of treatment has also been found for other addictive disorders (McKay, 2005
) and, notably, are consistent with the twelve-step approach to the treatment of substance use disorders. We are currently recruiting community-dwelling smokers for a study designed to replicate and extend the findings by Hall and colleagues. A similar study with smokers with recent alcohol dependence is also warranted.
Investigations of step-care treatments with this population are also needed. In step-care treatment, interventions are adjusted according to treatment response (McKay, 2005
). Most critically for smokers trying to quit, adjustments are considered to prevent an impending lapse or immediately following a lapse to prevent a relapse. In either case, medication dosage may be increased or a different medication added; frequency of counseling may also be adjusted. We could find no studies of the efficacy of lapse prevention and only two studies of step-care interventions for relapse prevention with smokers (Smith, Meyers and Miller 2001
; Juliano, Houtsmuller & Stitzer, 2006
). While these studies found no effects for step-care treatment, they had significant limitations, including a step-care intervention that was not lapse responsive (it was introduced to lapsers 14 days after their quit day regardless of when they lapsed) (Smith et al., 2001
) and a step-care intervention (i.e., rapid smoking) that was not well tolerated (Juliano et al., 2006
). Investigations of step-care approaches for lapse and relapse prevention for smoking and other addictive disorders are in their infancy. Research is clearly needed to investigate their efficacy for enhancing abstinence, including tobacco abstinence for smokers with alcohol histories.
Another important direction for future research is to identify individual difference variables that either increase or decrease the risk of relapse to alcohol with concurrent smoking and alcohol treatment. For example, it would be useful to identify individuals who are more vulnerable to experiencing a breakdown in self-control strength following a smoking cessation attempt (see Muraven & Baumeister, 2000
). An assessment of self-control strength conducted prior to initiation of smoking cessation treatment could be used to predict ability to maintain alcohol and other drug abstinence during a cessation attempt. This information could also be used to help prepare smokers who may be at risk for relapse to alcohol use following a cessation attempt.
At the same time, future research should identify individual difference factors that may decrease the risk of relapse to alcohol with concurrent smoking and alcohol treatment. For example, there may be individuals for who continued smoking during sobriety presents an important cue-based risk factor for a return to drinking, i.e., individuals with a high degree of cross-cue reactivity (Drobes, 2002
). Indirect evidence for this is suggested by studies investigating endophenotypes that mediate the relationship between a genotype and phenotype. For example, Hutchinson and colleagues have reported that a polymorphism in the D4
dopamine receptor, which has also been implicated in the development of incentive salience, is associated with individual differences in craving in cue reactivity studies with both smoking and alcohol cues (Hutchinson, LaChance, Niaura, Bryan & Smolen, 2002a
; Hutchinson, McGeary, Smolen, Bran & Swift, 2002b
; see also Robinson & Berridge, 2000
). These findings suggest that some alcoholic smokers who continue smoking during alcohol abstinence may be especially vulnerable to a return to drinking.