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...on nicotine
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www.ProjectCork.org
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Winter 2008
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Smoking kills (alcoholics)! Shouldn't we do something about it?
Littleton J; Barron S; Prendergast M; Nixon SJ. Alcohol and Alcoholism 42(3): 167-173, 2007. (93 refs.)
In general, 'drinkers smoke', and a high proportion of the alcohol-dependent population is also nicotine-dependent. Statistically, the majority of alcoholics will die of smoking-related, rather than alcohol-related, disease. This co-dependent subpopulation may have higher levels of nicotine dependence, and find smoking cessation more difficult. Major reasons are that concurrent alcohol use, and/or prior alcohol exposure, may change the reinforcing effects of nicotine, and that each drug becomes a pharmacological cue for the expectation of the other. If so, then smokers whose nicotine dependence is impacted by alcohol, represent a large and distinct sub-population in which both the therapeutic and molecular targets for smoking cessation are altered. This, in turn, has implications for the validity of animal models of nicotine reinforcement, and for the development of novel smoking cessation medications. It is no longer possible to ignore the fact that the two most prevalent and damaging addictive drugs in our society are very commonly used by the same individuals. Without a better understanding of the psychological and pharmacological interactions between alcohol and nicotine that impact dependence, we cannot hope to provide appropriate medications for this large and problematic patient group. Our intention in this opinion overview is to use the current literature to provide a framework for future studies into the impact of alcohol use on the reinforcing effects of nicotine. Copyright 2007, Oxford University Press.
Changes in smoking associated with an acute health event: Theoretical and practical implications.
Boudreaux ED; Baumann BM; Camargo CA; O'Hea E; Ziedonis DM. Annals of Behavioral Medicine 33(2): 189-199, 2007. (47 refs.)
Background. Experiencing a serious adverse behavior-related consequence may motivate behavior change. Purpose: To examine how a sentinel health event is associated with changes in smoking. Methods: We used a prospective cohort design. Adult emergency department (ED) patients provided demographic data, a smoking history, ratings of quit intentions, and endorsement of self-identified smoking-related health problems. A chart review collected data on acuity, ED disposition, and medical diagnoses. Smoking was reassessed I month postvisit. Hierarchical regression analyses were conducted to predict (a) intention to quit, (b) any quit attempt of 24 hr or more, and (3) 7-day abstinence. Results: Of 717 smokers enrolled, 189 (26%) intended to quit within the next month. Of the 253 participants reached I month postvisit, 126 (50%) reported they had attempted to quit, with 44 (19%) reporting 7-day abstinence. After controlling for other predictors, several event-related variables, such as having a smoking-related ED visit and being admitted to the hospital, were strong predictors of outcomes. Conclusion: Compared to community-based estimates, many more smokers in our sample attempted to quit and achieved 7-day abstinence. This was especially true among smokers who attributed their ED visit to a smoking-related health problem and who were admitted to the hospital. We discuss the implications for tobacco intervention design in medical settings. Copyright 2007, Lawrence Erlbaum.
Characteristics of Air Force personnel who choose pharmacological aids for smoking cessation following an involuntary tobacco ban and tobacco control program.
Klesges RC; Klesges LA; Weg MWV; DeBon M; Poston WSC; Ebbert J et al. Health Psychology 26(5): 588-597, 2007. (31 refs.)
Objective: The objective of this study was to compare characteristics of smokers who did and did not report use of cessation aids as part of a tobacco control program in a military setting (n = 8994). Design: The study is a longitudinal epidemiological study where the relationship between smoking status at follow-up and use of pharmacologic aids to quit smoking were assessed. Main Outcome Measures: Smoking cessation, post baseline use of cessation aids to quit smoking. Results and Conclusions: Individuals remaining abstinent were 70% less likely to have used NRT/pharmacological aids compared to those that relapsed. NRT/pharmacological aid users were more likely to report plans to smoke after military training, to have friends who smoke, and to accept a cigarette from a friend. NRT/pharmacological aid users were more likely to believe that using NRT was safer than smoking and to have engaged in harm reduction strategies. Our findings suggest that selection bias related to such characteristics may explain some of the discrepancies between effect sizes reported in efficacy compared to effectiveness studies of NRT and smoking outcomes currently reported in the literature. Copyright 2007, American Psychological Association.
Multivariate framework of the Brief Questionnaire of Smoking Urges.
Cappelleri JC; Bushmakin AG; Baker CL; Merikle E; Olufade AO; Gilbert DG. Drug and Alcohol Dependence 90(2/3): 234-242, 2007. (46 refs.)
We conducted an investigation of the 10-item Brief Questionnaire of Smoking Urges (QSU-Brief) to confirm its hypothesized two-factor structure and to assess the validity and reliability of its total score and these factors. Data were obtained from a 7-week clinical trial on smoking cessation (N=626). The hypothesized two-factor structure of the QSU-Brief was supported by fit indexes (>0.90) from a confirmatory factor analysis at each of three relevant time points (baseline, Week 2, Week 4). Corresponding values of Cronbach's alpha were acceptable (>0.75) on the Total Craving Score and on Factors 1 and 2. This research supports the validity and reliability of the instrument and confirms the proposed two-dimensional structure of self-reported craving as measured by the QSU-Brief. Copyright 2007, Elsevier Science.
Cost-effectiveness analysis of a European primary-care physician training in smoking cessation counseling.
Pinget C; Martin E; Wasserfallen JB; Humair JP; Cornuz J. European Journal of Cardiovascular Prevention & Rehabilitation 14(3): 451-455, 2007. (20 refs.)
Background: Physician training in smoking cessation counseling has been shown to be effective as a means to increase quit success. We assessed the cost-effectiveness ratio of a smoking cessation counseling training programme. Its effectiveness was previously demonstrated in a cluster randomized, control trial performed in two Swiss university outpatients clinics, in which residents were randomized to receive training in smoking interventions or a control educational intervention. Design and methods: We used a Markov simulation model for effectiveness analysis. This model incorporates the intervention efficacy, the natural quit rate, and the lifetime probability of relapse after 1-year abstinence. We used previously published results in addition to hospital service and outpatient clinic cost data. The time horizon was 1 year, and we opted for a third-party payer perspective. Results The incremental cost of the intervention amounted to US$2.58 per consultation by a smoker, translating into a cost per life-year saved of US$25.4 for men and 35.2 for women. One-way sensitivity analyses yielded a range of US$4.0-107.1 in men and US$9.7-148.6 in women. Variations in the quit rate of the control intervention, the length of training effectiveness, and the discount rate yielded moderately large effects on the outcome. Variations in the natural cessation rate, the lifetime probability of relapse, the cost of physician training, the counseling time, the cost per hour of physician time, and the cost of the booklets had little effect on the cost-effectiveness ratio. Conclusions: Training residents in smoking cessation counseling is a very cost-effective intervention and may be more efficient than currently accepted tobacco control interventions. Copyright 2007, Lippincott, Williams & Wilkins.
Costs and benefits of smoking cessation aids:
Making a case for public reimbursement of nicotine replacement therapy in Australia.
Bertram MY; Lim SS; Wallace AL; Vos T. Tobacco Control 16(4): 255-260, 2007. (39 refs.)
Background: Tobacco smoking is the leading preventable cause of morbidity and mortality in Australia and other developed countries. Of the pharmacological aids that are available for smoking cessation, bupropion (Zyban SR) is eligible for public reimbursement on the Australian Pharmaceutical Benefits Scheme (PBS), whereas nicotine replacement therapy (NRT) is not. Information on the cost-effectiveness and financial impact of public reimbursement of these strategies can better inform debate about their inclusion or exclusion in public reimbursement schemes. Objective: To estimate the cost-effectiveness of bupropion and NRT, and the potential financial impact of public reimbursement of NRT in Australia. Design: A cost-effectiveness analysis using a deterministic Markov model, and cost per disability-adjusted life year (DALY) averted over a lifetime as the outcome measure. Population: Current smokers, motivated to quit, in Australia in 2000. Interventions: (1) NRT; (2) bupropion; and (3) a combined strategy using bupropion as the first-line treatment and NRT in those who fail to quit smoking or have adverse reactions to bupropion. Results: Quitting smoking can increase life expectancy of current smokers by 1-7.6 years depending on age at cessation and sex. Providing bupropion to current smokers who are motivated to quit would cost A$ 7900 (95% uncertainty interval A$ 6000 to A$ 10 500) for each DALY averted; NRT patches would cost A$ 17 000 (A$ 9000 to A$ 28 000) for each DALY averted, with similar results even if used as a second-line treatment following initial failure to quit using bupropion. If 6% of current smokers were to use NRT following inclusion on the PBS, this would result in an annual cost of A$ 40-110 million to the PBS depending on the listed price. Conclusions: Compared with other drugs included on the PBS, bupropion and NRT are both highly costeffective smoking cessation interventions, and including NRT on the PBS would have a moderate financial impact. Given the sizeable health burden of smoking, and the large individual benefits of quitting smoking, increasing the availability of alternative aids and uptake of these strategies through public reimbursement would be a positive and rational step towards further reducing tobacco-related disease burden in Australia and other countries where NRT is currently not subsidised. Copyright 2007, BMJ Publishing Group.
Cigarette smoking and lung cancer - Modeling effect modification of total exposure and intensity.
Lubin JH; Caporaso N; Wichmann HE; Schaffrath-Rosario A; Alavanja MCR. Epidemiology 18(5): 639-648, 2007. (49 refs.)
Background: A recent analysis indicates that the excess odds ratio for lung cancer by smoking is described by a function that is linear in pack-years and exponential in the logarithm of smoking intensity and its square (Cancer Epidemiology Biomarkers Prev. 2006;15:517i, s i, 52 he model suggests that below 15-20 cigarettes per day there a direct exposure rate" effect, ie, the excess odds ratio per pack-year for higher intensity (and shorter duration) smokers is greater than for lower-intensity (and longer duration) smokers. Above 20 cigarettes per day, there is an "inverse-exposure-rate" effect, ie, the excess odds ratio per pack-year for higher intensity smokers is smaller than for lower-intensity smokers. Methods: Using pooled data from 2 large case-control studies of lung cancer (the European Smoking and Health Study and the German Radon Study), we evaluated effect modification of the association between smoking and lung cancer. Results: Interaction effects are very specific. Variations in risk of lung cancer with years since cessation of smoking, age, method of inhalation, and type of cigarette result from interactions with smoking intensity, and not total pack-years. In contrast, risk variations by sex result from the interaction with total pack-years, while intensity effects are homogeneous. Risk variations by age at which smoking started result from interactions with both total pack-years and intensity. All intensity interactions are homogeneous across studies. Conclusions: The specificity of the interactions may provide clues for the molecular basis of the smoking and lung cancer relationship. Copyright 2007, Lippincott, Williams & Wilkins.
Harm perception of nicotine products in college freshmen.
Smith SY; Curbow B; Stillman FA. Nicotine & Tobacco Research 9(9): 977-982, 2007. (20 refs.)
This study examined the association of sociodemographic characteristics and smoking behaviors (i.e., cigarette, cigar, and waterpipe) with nicotine product harm perception in college freshmen. Students were asked to compare the perceived harmfulness of 11 nicotine-delivering products with that of a regular cigarette. Data were from a cross-sectional Internet survey conducted during the spring 2004 semester at a private university (N=411). Binomial logistic regression was used to determine the association between sociodemographic and behavioral factors with nicotine product harm perception. A statistically significant association was found between nicotine product harm perception and sex, race, income, citizenship, and smoking behavior (p <=.05). Regarding the three medicinal nicotine replacement therapies, 19.6% of respondents incorrectly perceived the nicotine patch to be as harmful as or more harmful than a regular cigarette; corresponding values were 24.1% for nicotine gum and 52.9% for nicotine inhaler. Respondents incorrectly perceived the following smoked tobacco products to be less harmful than regular cigarettes: ultra-light cigarettes (40.4%), waterpipe (37%), light cigarettes (35.2%), cigarillos (17.4%), and cigars (16.9%). Regarding smokeless nicotine products, 89.3% of respondents incorrectly perceived dip and chew to be as harmful as or more harmful than regular cigarettes; corresponding values were 36.2% for nicotine lollipops and 35.2% for nicotine water. Our findings reveal misperceptions about nicotine product harmfulness and underscore the importance of developing a science base to inform policies and educate consumers about these products. Copyright 2007, Taylor & Francis.
Pharmacogenetics and smoking cessation with nicotine replacement therapy.
Ray R; Schnoll RA; Lerman C. CNS Drugs 21(7): 525-533, 2007. (79 refs.)
Nicotine replacement therapies (NRTs), including transdermal patch, gum, lozenge, nasal spray and inhaler, are widely used for the treatment of tobacco dependence; however, only one-quarter to one-third of smokers who utilise NRTs to quit smoking are able to maintain long-term abstinence from tobacco use. Pharmacogenetic studies of NRT may be useful to identify subgroups of smokers who respond more favourably to specific NRTs, and to determine the optimal dose and duration of NRT. To date, pharmacogenetic studies have examined genes coding for nicotine metabolising enzymes, as well as proteins in neurotransmitter pathways that mediate the effects of nicotine. Initial findings suggest that polymorphisms in nicotine metabolising enzymes, and selected genes in the dopaminergic and opioidergic pathways, may have predictive validity for NRT response; however, independent replication is necessary before translation to clinical practice. Larger scale investigations that incorporate pathway-based or genome-wide analysis, as well as intermediate measures of nicotine dependence (i.e. 'endophenotypes'), may be necessary to capture the complexity of pharmacogenetic effects. Copyright 2007, Adis International.
Prospective determinants of smoking cessation in COPD patients within a high intensity or a brief counseling intervention.
Christenhusz L; Marcel P; Erwin S; van der Palen J. Patient Education and Counseling 66(2): 162-166, 2007. (16 refs.)
Objectives: The aims of this study were to identify prospective determinants of smoking cessation in COPD patients, and to assess whether prospective determinants vary between two different cessation interventions. Methods: Two hundred and twenty-five moderate to severe COPD patients were randomly allocated to two smoking cessation interventions. One-year cotinine-validated continuous abstinence rates were 9% for the minimal intervention strategy for lung patients (LMIS) and 19% for the SmokeStopTherapy (SST). The baseline characteristics that showed a significant univariate relationship with 1-year continuous abstinence (p < .20) were included in the logistic regression model. This procedure was performed for each intervention separately. Variables that did not remain independent predictors were removed. Results: For the SST separately, no independent significant predictor remained. For the LMIS, attitude towards smoking cessation (OR: 11.8; 95% CI: 1.7-81.5; p = .013) and cotinine level (OR: 2.1; 95% CI: 1.08-3.93; p = .028) remained significant predictors. Within the LMIS, 31% of the variance in continuous abstinence was explained by these variables (p = .003). Conclusion: This study suggests that a moderately intensive intervention (LMIS) is primarily suitable for COPI) patients with a positive attitude regarding smoking cessation. The more intensive SST can be an alternative for patients without such baseline characteristic. Practice implications: This stepped-care approach in smoking cessation counseling may be useful in clinical practice and will enable health care providers to match interventions to individual needs and increase efficiency. Copyright 2007, Elsevier Science.
Results from two pharmacotherapy trials show alcoholic smokers were more severely alcohol dependent but less prone to relapse than alcoholic non-smokers.
Schmidt LG; Smolka MN. Alcohol and Alcoholism42(3): 241-246, 2007. (39 refs.)
Aims: To assess the role of smoking on treatment outcome in quitting alcoholics on the background of the priming or coping hypothesis (Rohsenow et al., 1997). Methods: Data sets of placebo treated patients of the German phase III trial of naltrexone (Gastpar et al., 2002) and of acamprosate treated patients of a German phase IV trial (Soyka et al., 2002) were reanalyzed. Differences between smoking and non-smoking alcoholics were evaluated using chi(2)-, t- or ANOVA-tests, relapse rates using survival techniques with Cox regression. Results: Smoking alcoholics differed significantly from non-smoking alcoholics regarding sociodemographic variables (e.g. more males, more often living alone) and severity indicators of alcoholism (e.g. quantity, onset, related problems). In the naltrexone study time to first relapse was significantly longer for smoking alcoholics compared to non-smoking alcoholics (hazard ratio = 2.26; P = 0.036). The same effect was seen in the acamprosate study (hazard ratio = 1.34; P = 0.015); estimated abstinence-rates after 24 weeks were 38% for smoking alcoholics compared to 28% for non-smoking alcoholics (P < 0.015). Conclusions: Smoking was significantly associated with better outcome in recovering alcoholics included in two pharmacotherapy trials. Although the underlying mechanisms remain unclear our findings are in favour of the coping hypothesis. The results challenge the validity of the dependence syndrome. Copyright 2007, Oxford University Press.
The effects of providing lung age and respiratory symptoms feedback on community college smokers' perceived smoking-related health risks, worries and desire to quit.
Lipkus IM; Prokhorov AV. Addictive Behaviors 32(3): 516-532, 2007. (43 refs.)
This study examined the effects of providing lung age, as assessed via a lung function test (spirometry), and respiratory symptoms feedback on college smokers' perceived smoking-related risks, worries and desire to quit. We also investigated whether smokers reacted defensively to this feedback. One hundred and twenty-four smokers were randomized to either receive lung age and respiratory symptoms feedback (intervention group) or a brochure containing facts about smoking only (control group). Perceived risks, worries and desire to quit did not differ between groups. In both groups, worries, but not perceived risks, were correlated with a stronger desire to quit. With increasing lung age, smokers rated the feedback as less relevant and reported exerting less effort breathing in and out while undergoing spirometry. The latter two outcomes were associated with less worry. These findings suggest that lung age and respiratory symptoms feedback does not translate readily into appreciable changes in motivation to quit as well as do other often reported mediators of change (e.g., perceived risks and worries). Copyright 2007, Elsevier Science.
Tobacco use in women with lung cancer.
Cooley ME; Sarna L; Brown JK; Williams RD; Chernecky C; Padilla G et al. Annals of Behavioral Medicine 33(3): 242-250, 2007. (53 refs.)
Background. Smoking cessation after a cancer diagnosis is associated with improved clinical outcomes. Purpose: The aims of this study are to determine smoking prevalence, describe patterns of smoking, identify readiness to quit and cessation strategies, identify factors associated with continued smoking among women with lung cancer, and determine smoking prevalence among household members. Methods: Data were collected through questionnaires and medical record review from 230 women. Smoking was determined through self-report and biochemical verification with urinary cotinine. Results: Eighty-seven percent of women reported ever-smoking, and 37% reported smoking at the time of diagnosis. Ten percent of women were smoking at entry to the study, 13% were smoking at 3 months, and 11% at 6 months. Fifty-five percent of smokers planned a quit attempt within the next month. One third of smokers received cessation assistance at diagnosis, and pharmacotherapy was the most common strategy. Significant factors associated with continued smoking included younger age, depression, and household member smoking. Continued smoking among household members was 21%. Twelve percent of household members changed their smoking behavior; 77% quit smoking, but 12% started smoking. Conclusions: The diagnosis of cancer is a strong motivator for behavioral change, and some patients need additional support to quit smoking. Family members should also be targeted for cessation interventions. Copyright 2007, Lawrence Erlbaum Associates.
Light cigarette smoking impairs coronary microvascular functions as severely as smoking regular cigarettes.
Gullu H; Caliskan M; Ciftci O; Erdogan D; Topcu S; Yildirim E et al. Heart 93(10): 1274-1277, 2007. (19 refs.)
Background: Smoking is the most prevalent and most preventable risk factor for cardiovascular diseases. Smoking low-tar, low-nicotine cigarettes (light cigarettes) would be expected to be less hazardous than smoking regular cigarettes owing to the lower nicotine and tar yield. Objective: To compare the chronic and acute effects of light cigarette and regular cigarette smoking on coronary flow velocity reserve (CFVR). Methods: 20 regular cigarette smokers (mean (SD) age 24.8 (5.0)), 20 light cigarette smokers (mean age 25.6 (6.4)), and 22 non-smoker healthy volunteers (mean age 25.1 (4.2)) were included. First, each subject underwent echocardiographic examination, including CFVR measurement, after a 12 hour fasting and smokeless period. Two days later, each subject smoked two of their normal cigarettes in a closed room within 15 minutes. Finally, within 20-30 minutes, each subject underwent an echocardiographic examination, including CFVR measurement. . Results: Mean (SD) CFVR values were similar in light cigarette and regular cigarette smokers and significantly lower than in the controls (2.68 (0.50), 2.65 (0.61), 3.11 (0.53), p = 0.013). Before and after smoking a paired t test showed that smoking two light cigarettes acutely decreased the CFVR from 2.68 (0.50) to 2.05 (0.43) (p = 0.001), and smoking of two regular cigarettes acutely decreased CFVR from 2.65 (0.61) to 2.18 (0.48) (p = 0.001). Conclusion: Smoking low-tar, low-nicotine cigarettes impairs the CFVR as severely as smoking regular cigarettes. CFVR values are similar in light cigarette and regular cigarette smokers and significantly lower than in controls. Copyright 2007, BMJ Publishing Group.
Effects of instructions on responses to the nicotine patch: A laboratory study.
Fucito LM; Juliano LM. Psychopharmacology 194(4): 475-483, 2007. (33 refs.)
Rationale: Smokers have weak positive expectancies for nicotine replacement therapies relative to smoking (Juliano and Brandon, Nicotine Tob Research, 6:569-574, 2004). Objectives: This study investigated if a manipulation designed to alter expectancies for the nicotine patch was effective in increasing positive expectancies for the patch and influencing smoking cessation outcomes during a 2-day abstinence period. Materials and methods Smokers (n=72) were randomly assigned to receive information that emphasized either patch benefits (n=25) or standard patch information including side effects (n=25). Participants wore placebo patches but were told that the patches contained nicotine. A control condition (n=22) was informed that they received placebo patches while given standard patch information to independently test the effect of the nicotine-dose instructional set on abstinence outcomes. Results Benefits information significantly increased positive expectancies for the patch and promoted positive mood during the abstinence period relative to the side effects information. Nicotine-dose instructions resulted in fewer lapsed cigarettes and higher ratings of patch helpfulness than placebo instructions. In particular, women's smoking behavior appeared to be more influenced by nicotine instructions than that of men. Conclusions: The results of this preliminary study suggest that information provided to smokers about patch effects and nicotine content may influence behavioral and subjective outcomes of patch use. Copyright 2007, Springer.
Differential impact of state tobacco control policies among race and ethnic groups. (review).
Tauras JA. Addiction102(Supplement 2): 95-103, 2007. (35 refs.)
Aims: This paper describes patterns of racial and ethnic cigarette use in the United States and discusses changes in state-level tobacco control policies. Moreover, this paper reviews the existing econometric literature on racial and ethnic smoking and discusses the limitations of that research. Finally, this paper outlines an agenda for future research. Methods Patterns of racial and ethnic smoking and changes in state-level tobacco control policies in the United States were obtained from a variety of sources, including surveys and government and private documents and databases. After an extensive literature search was completed, the existing research was scrutinized and recommendations for much-needed future research were put forth. Findings Despite the fact that certain racial and ethnic minorities bear a disproportionate share of the overall health burden of tobacco, less than a handful of econometric studies have examined the effects of state-level public policies on racial and ethnic smoking. The existing literature finds Hispanics and African Americans to be more responsive to changes in cigarette prices than whites. Only one study examined other state-level tobacco policies. The findings from that study implied that adolescent white male smoking was responsive to changes in smoke-free air laws, while adolescent black smoking was responsive to changes in youth access laws. Conclusions: While much has been learned from prior econometric studies on racial and ethnic smoking in the United States, the existing literature suffers from numerous limitations that should be addressed in future research. Future studies should hold sentiment toward tobacco constant and control for tobacco policies that take into account not only the presence of the laws, but also the level of restrictiveness of each policy. Copyright 2007, Society for the Study of Addiction to Alcohol and Other Drugs.
Time-varying predictors of smoking cessation among individuals in treatment for alcohol abuse and dependence: Findings from Project Match.
Friend KB; Pagan ME. Alcohol and Alcoholism 42(3): 234-240, 2007. (64 refs.)
Aims: Individuals in treatment for alcohol use disorders are more likely to die from cigarette use than from alcohol consumption. Advanced statistical methodologies that increase study power and clinical relevance have been advocated to examine the time varying nature of substance use relapse and abstinence, including drinking and smoking. The purpose of this investigation was to examine time varying factors that are associated with smoking cessation among smokers in the general population, including alcohol use, self-efficacy, and depression, to determine if they were also related to smoking cessation during and after treatment for alcohol use disorders. Methods: Data: were garnered from Project MATCH, a longitudinal study of the efficacy of 3 behavioural treatments for alcohol use disorders. Timevarying covariate analyses were conducted to examine future smoking cessation. Results: Greater self-efficacy regarding resisting temptations to drink and lower levels of depression were independently associated with increased likelihood of stopping smoking. In contrast, drinks per drinking day and confidence regarding not drinking did not demonstrate such associations. Conclusions: Clinical implications of these findings suggest that interventions to help alcoholics in recovery avoid temptations to drink, as well as decrease depression, may be warranted. These statistical techniques, these results can help clinicians and organizations working with smokers in treatment for alcohol use disorders to make informed decisions regarding how best to use limited resources. Copyright 2007, Oxford University Press.
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