Tobacco Dependence Treatment Grants: A Collaborative Approach to the Implementation of WHO Tobacco Control Initiatives.

The number of global tobacco-related deaths is projected to increase from about 6 million to 8 million annually by 2030, with more than 80% of these occurring in low- and middle-income countries (LMICs). The World Health Organization Framework Convention on Tobacco Control (FCTC) came into force in 2005 and Article 14 relates specifically to the treatment of tobacco dependence. However, LMICs, in particular, face several barriers to implementing tobacco dependence treatment. This paper is a descriptive evaluation of a novel grant funding mechanism that was initiated in 2014 to address these barriers. Global Bridges. Healthcare Alliance for Tobacco Dependence Treatment aims to create and mobilize a global network of healthcare professionals and organizations dedicated to advancing evidence-based tobacco dependence treatment and advocating for effective tobacco control policy. A 2014 request for proposals (RFP) focused on these goals, particularly in LMICs, where funding for this work had been previously unavailable. 19 grants were awarded by Global Bridges to organizations in low- and middle-income countries across all six WHO regions. Virtually all focused on developing a tobacco dependence treatment curriculum for healthcare providers, while also influencing the political environment for Article 14 implementation. As a direct result of these projects, close to 9,000 healthcare providers have been trained in tobacco dependence treatment and an estimated 150,000 patients have been offered treatment. Because most of these projects are designed with a "train-the-trainer" component, two years of grant funding has been a tremendous catalyst for accelerating change in tobacco dependence treatment practices throughout the world. In order to foster such exponential growth and continue to maintain the impact of these projects, ongoing financial, educational, and professional commitments are required.

Varenicline for tobacco-dependence treatment in alcohol-dependent smokers: A randomized controlled trial.

BACKGROUND: Tobacco use is prevalent among persons with alcohol abuse and dependence. Varenicline has been shown to be the most effective pharmacotherapy for smoking cessation and may decrease alcohol consumption. The purpose of this study was to evaluate the efficacy of 12 weeks of varenicline for increasing smoking abstinence rates in smokers with alcohol abuse or dependence. METHODS: Participants were eligible for enrollment if they were 18 years or older, smoked 10 or more cigarettes per day for at least 6 months, had current alcohol abuse or dependence, and were interested in quitting smoking. Participants were randomly assigned to receive 12 weeks of varenicline 1 mg twice daily or matching placebo. The primary end point was 7-day point prevalence smoking abstinence at week 12. RESULTS: The 7-day point prevalence smoking abstinence rate at 12 weeks was significantly higher with varenicline (n = 16) than placebo (n = 17) (43.8% vs 5.9%; P = .01). At 24 weeks, the 7-day point prevalence smoking abstinence rate was still significantly higher with varenicline than placebo (31.3% vs 0%; P = .02). At 12 weeks, mean (SD) drinks per drinking day was significantly lower with varenicline than placebo (5.7 [3.9] vs 9.0 [5.3] drinks; treatment effect estimate, -2.8 [90% CI, -6.6 to -1.0]). Adverse events were minor and comparable to varenicline clinical trials. CONCLUSIONS: Varenicline is safe and efficacious for increasing smoking abstinence rates in smokers with alcohol abuse or dependence. Varenicline may decrease alcohol consumption in this population of smokers.

[The Mayo Clinic Nicotine Dependence Center]. / Centrum závislosti na nikotinu pri Mayo Clinic.

Since 1988, this world leading center provided treatment of tobacco dependence to tens of thousands of tobacco-dependent patients, educated thousands of health professionals and has rich research activities. Its system was a model for such similar centers including those in the Czech Republic.

Impact of a countywide smoke-free workplace law on emergency department visits for respiratory diseases: a retrospective cohort study.

BACKGROUND: With the goal of reducing exposure to secondhand smoke, the state of Minnesota (MN), enacted a smoke-free law (i.e., Freedom to Breathe Act) in all workplaces, restaurants, and bars in 2007. This retrospective cohort study analyzes emergency department (ED) visits in Olmsted County, MN, for chronic obstructive pulmonary disease (COPD) and asthma over a five-year period to assess changes after enactment of the smoke-free law. METHODS: We calculated the rates of ED visits in Olmsted County, MN, with a primary diagnosis of COPD and asthma in the five-year period from January 1, 2005 to December 31, 2009. Analyses were performed using segmented Poisson regression to assess whether ED visit rates declined following enactment of the smoke free law after adjusting for potential underlying temporal trends in ED visit rates during this time period. RESULTS: Using segmented Poisson regression analyses, a significant reduction was detected in asthma-related ED visits (RR 0.814, p < 0.001) but not for COPD-related ED visits following the enactment of the smoke-free law. The reduction in asthma related ED visits was observed in both adults (RR 0.840, p = 0.015) and children (RR 0.751, p = 0.015). CONCLUSIONS: In Olmsted County, MN, asthma-related ED visits declined significantly after enactment of a smoke-free law. These results add to the body of literature supporting community health benefits of smoke-free policies in public environments and their potential to reduce health care costs.

Did we finally slay the evil dragon of cigarette smoking in the late 20th century?: unfortunately, the answer is no - the dragon is still alive and well in the 21st century and living in the third world. Shame on us!

If cigarettes were introduced as a new consumer product today, it is unlikely they would receive government regulatory approval. Cigarettes have proven biologic toxicities (carcinogenesis, atherogenesis, teratogenesis) and well-established causal links to human disease. Things were very different in 1913 when the R. J. Reynolds Tobacco Company introduced the first modern cigarette, the iconic Camel. By the early 1950s, definitive scientific reports linked cigarettes and human disease, but it was more than a half century later (2006) that cigarette manufacturers were found guilty by a federal court of deceptive product marketing regarding the health hazards of tobacco use. In the United States, cigarette smoking remains a major but slowly declining problem. But in developing countries, cigarette use is expanding tremendously. In global terms, the epidemic of smoking-caused disease is projected to increase rapidly in coming decades, not decline. Society may have begun to slowly win the smoking battle in the developed world, but we are resoundingly losing the global war on smoking. All is not lost! There is some good news! The 2003 Framework Convention on Tobacco Control, supported strongly by the American College of Chest Physicians, is the first global public health treaty of the new millennium. Many developed societies have begun planning to rid their countries of cigarettes in what is called the Endgame Strategy, and now is the time for the international medical community to help change tobacco policy to a worldwide endgame approach to rid all humanity of smoking-related diseases.

Combination varenicline and bupropion SR for tobacco-dependence treatment in cigarette smokers: a randomized trial.

IMPORTANCE: Combining pharmacotherapies for tobacco-dependence treatment may increase smoking abstinence. OBJECTIVE: To determine efficacy and safety of varenicline and bupropion sustained-release (SR; combination therapy) compared with varenicline (monotherapy) in cigarette smokers. DESIGN, SETTING, AND PARTICIPANTS: Randomized, blinded, placebo-controlled multicenter clinical trial with a 12-week treatment period and follow-up through week 52 conducted between October 2009 and April 2013 at 3 midwestern clinical research sites. Five hundred six adult (≥18 years) cigarette smokers were randomly assigned and 315 (62%) completed the study. INTERVENTIONS: Twelve weeks of varenicline and bupropion SR or varenicline and placebo. MAIN OUTCOMES AND MEASURES: Primary outcome was abstinence rates at week 12, defined as prolonged (no smoking from 2 weeks after the target quit date) abstinence and 7-day point-prevalence (no smoking past 7 days) abstinence. Secondary outcomes were prolonged and point-prevalence smoking abstinence rates at weeks 26 and 52. Outcomes were biochemically confirmed. RESULTS: At 12 weeks, 53.0% of the combination therapy group achieved prolonged smoking abstinence and 56.2% achieved 7-day point-prevalence smoking abstinence compared with 43.2% and 48.6% in varenicline monotherapy (odds ratio [OR], 1.49; 95% CI, 1.05-2.12; P = .03 and OR, 1.36; 95% CI, 0.95-1.93; P = .09, respectively). At 26 weeks, 36.6% of the combination therapy group achieved prolonged and 38.2% achieved 7-day point-prevalence smoking abstinence compared with 27.6% and 31.9% in varenicline monotherapy (OR, 1.52; 95% CI, 1.04-2.22; P = .03 and OR, 1.32; 95% CI, 0.91-1.91; P = .14, respectively). At 52 weeks, 30.9% of the combination therapy group achieved prolonged and 36.6% achieved 7-day point-prevalence smoking abstinence compared with 24.5% and 29.2% in varenicline monotherapy (OR, 1.39; 95% CI, 0.93-2.07; P = .11 and OR, 1.40; 95% CI, 0.96-2.05; P = .08, respectively). Participants receiving combination therapy reported more anxiety (7.2% vs 3.1%; P = .04) and depressive symptoms (3.6% vs 0.8%; P = .03). CONCLUSIONS AND RELEVANCE: Among cigarette smokers, combined use of varenicline and bupropion, compared with varenicline alone, increased prolonged abstinence but not 7-day point prevalence at 12 and 26 weeks. Neither outcome was significantly different at 52 weeks. Further research is required to determine the role of combination therapy in smoking cessation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: http://clinicaltrials.gov/show/NCT00935818.

A randomized phase II clinical trial of high-dose nicotine patch therapy for smokeless tobacco users.

INTRODUCTION: Nicotine patch therapy has not been shown to be efficacious for increasing long-term (≥6 months) tobacco abstinence rates among smokeless tobacco (ST) users. Higher doses of nicotine patch therapy may be needed to increase tobacco abstinence rates in this population of tobacco users. METHODS: We randomized ST users who used ≥3 cans/pouches per week to either 8 weeks of high-dose nicotine patch therapy (42mg/day) or matching placebo patch. Subjects were followed for 6 months after randomization. RESULTS: Fifty-two subjects were randomized. Compared with placebo, high-dose nicotine patch therapy was associated with significantly higher prolonged tobacco abstinence at end-of-treatment (44% vs. 22%, odds ratio [OR] = 2.7, p = .050) and 3 months (40% vs. 19%, OR = 2.9, p = .047). High-dose nicotine patch therapy was associated with significant weight gain attenuation among tobacco abstinence subjects at 3 months (p = .013) and 6 months (p = .018). Compared with placebo, high-dose nicotine patch therapy was associated with nonsignificantly lower nicotine withdrawal scores. Adverse events were not significantly increased with high-dose nicotine patch therapy. CONCLUSIONS: High-dose nicotine patch therapy is safe and increases short-term tobacco abstinence rates among ST users who use ≥3 cans/pouches per week. High-dose nicotine patch therapy is associated with significant long-term attenuation of weight gain. Future studies to investigate the long-term efficacy of high-dose nicotine patch therapy and the comparative efficacy of this approach compared with standard nicotine patch doses for ST users seems warranted.

Myocardial infarction and sudden cardiac death in Olmsted County, Minnesota, before and after smoke-free workplace laws.

BACKGROUND: Reductions in admissions for myocardial infarction (MI) have been reported in locales where smoke-free workplace laws have been implemented, but no study has assessed sudden cardiac death in that setting. In 2002, a smoke-free restaurant ordinance was implemented in Olmsted County, Minnesota, and in 2007, all workplaces, including bars, became smoke free. METHODS: To evaluate the population impact of smoke-free laws, we measured, through the Rochester Epidemiology Project, the incidence of MI and sudden cardiac death in Olmsted County during the 18-month period before and after implementation of each smoke-free ordinance. All MIs were continuously abstracted and validated, using rigorous standardized criteria relying on biomarkers, cardiac pain, and Minnesota coding of the electrocardiogram. Sudden cardiac death was defined as out-of-hospital deaths associated with coronary disease. RESULTS: Comparing the 18 months before implementation of the smoke-free restaurant ordinance with the 18 months after implementation of the smoke-free workplace law, the incidence of MI declined by 33% (P < .001), from 150.8 to 100.7 per 100,000 population, and the incidence of sudden cardiac death declined by 17% (P = .13), from 109.1 to 92.0 per 100,000 population. During the same period, the prevalence of smoking declined and that of hypertension, diabetes mellitus, hypercholesterolemia, and obesity either remained constant or increased. CONCLUSIONS: A substantial decline in the incidence of MI was observed after smoke-free laws were implemented, the magnitude of which is not explained by community cointerventions or changes in cardiovascular risk factors with the exception of smoking prevalence. As trends in other risk factors do not appear explanatory, smoke-free workplace laws seem to be ecologically related to these favorable trends. Secondhand smoke exposure should be considered a modifiable risk factor for MI. All people should avoid secondhand smoke to the extent possible, and people with coronary heart disease should have no exposure to secondhand smoke.

Tobacco dependence counseling in a randomized multisite clinical trial.

Pharmacotherapy trials for treating tobacco dependence would benefit from behavioral interventions providing treatment consistent with clinical practice guidelines but not directing participants to treatments not evaluated in the trial. The Smoke Free and Living It© behavioral intervention manual includes participant and interventionist guides and is designed to provide both practical counseling and intra-treatment support. We utilized this intervention manual in a multicenter, randomized clinical trial of smokers with attention deficit hyperactivity disorder. In this study, we evaluated how the interventional manual performed in a "train-the-trainer" model requiring uniform counseling across 6 sites and 15 interventionists. We analyzed the skill-adherence of the interventionists and the intervention-adherence of the participants. The 255 randomized participants completed 9.3±2.8 sessions (mean±SD), with 157 participants (61.6%) completing all 11 of the sessions and 221 (86.7%) completing at least 6 of the 11 sessions. Of the 163 sessions for which the study interventionists were evaluated, 156 (95.7%) were rated as adherent to protocol and "meeting expectations" on at least 6 of 7 established criteria, illustrating that fidelity can be maintained with minimal supervision. The self-help and interventionists guides of the Smoke Free and Living It manual can thus be used to provide behavioral intervention with a high rate of adherence by both the interventionists and the participants. This manual meets the requirements of the United States Public Health Service Clinical Practice Guideline, can be adapted to specific research protocols, and provides a useful option for behavioral intervention during clinical trials for smoking cessation.

Roadmap to a tobacco epidemic: transnational tobacco companies invade Indonesia.

BACKGROUND: Indonesia is the world's fifth largest cigarette market in the world but for decades, transnational tobacco companies (TTCs) have had limited success infiltrating this market, due to their inability to compete in the kretek market. Kreteks are clove/tobacco cigarettes that most Indonesians smoke. OBJECTIVE: To determine how Phillip Morris International (PMI) and British American Tobacco (BAT) have now successfully achieved a substantial market presence in Indonesia. METHODS: We analyzed previously secret, tobacco industry documents, corporate reports on Indonesia operations, the Tobacco Trade press, Indonesia media, and "The Roadmap". RESULTS: Internal, corporate documents from BAT and PMI demonstrate that they had known for decades that kreteks are highly carcinogenic. Despite that knowledge, BAT and PMI now own and heavily market these products, as well as new more westernised versions of kreteks. BAT and PMI used their successful basic strategy of keeping cigarettes affordable by maintaining the social responsibility of smoking and opposing smoke-free workplace laws but in the 21st century, they added the acquisition of and westernisation of domestic kretek manufacturers as an additional strategy. These acquisitions allowed them to assert influences on health policy in Indonesia and to grow their business under current government policy embodied in the 2007-2020 Roadmap of Tobacco Products Industry and Excise Policy which calls for increased cigarette production by 12% over the next 15 years. CONCLUSION: PMI and Bat have successfully entered and are expanding their share in the Indonesia cigarette market. Despite the obvious and pervasive influence of the tobacco industry on policy decisions, the Indonesian government should ratify the FCTC and implement effective legislation to reduce tobacco consumption and exposure to tobacco smoke and revise the Roadmap to protect future generations of Indonesians.

Preventing lung cancer by treating tobacco dependence.

Tobacco use is a chronic medical disorder. Providing evidence-based treatment of tobacco-dependent patients is a challenge, and a team approach provides an efficient treatment model. Tobacco treatment specialists could expand the collective tobacco treatment expertise in the medical setting. Effective tobacco dependence treatment frequently requires tailoring and intensifying of interventions to meet the needs of the individual patient. Stopping smoking reduces the risk of lung cancer and many other cancers, cardiovascular disease, stroke, peripheral vascular disease. Treating tobacco dependence is one of the most cost-effective therapies in medicine and it deserves adequate reimbursement for it to be more widely available.

An exploration of site effects in a multisite trial of OROS-methylphenidate for smokers with attention deficit/hyperactivity disorder.

BACKGROUND: Multisite trials, the gold standard for conducting studies in community-based settings, can mask variability across sites resulting in misrepresentation of effects in specific sites. In a placebo-controlled trial of osmotic-release oral system methylphenidate (OROS-MPH) as augmentation treatment for smokers with attention deficit hyperactivity/impulsivity disorder (ADHD), three types of sites were selected according to their clinical research specialty (ADHD, smoking cessation, and general mental health). OBJECTIVE: Analysis was conducted to determine if clinical outcomes, that is, reduction in ADHD symptoms and smoking cessation rates, and the effect of treatment on these outcomes would differ by type of site. METHOD: A total of 255 adult smokers diagnosed with ADHD were enrolled in three clinic types: 72 in ADHD, 79 in tobacco dependence, and 104 in the mental health clinics. RESULTS: The three site-types were similar in demographic characteristics, smoking history, baseline level of ADHD symptoms, and history of psychiatric illness. Site-type but not a site-type by treatment interaction predicted prolonged smoking abstinence. A significant three-way interaction of site-type, treatment, and time-predicted improvement in ADHD symptoms. Moderate to strong effects of OROS-MPH relative to placebo were observed in the mental health and the ADHD clinics; a weak effect was observed in the tobacco dependence clinics. CONCLUSION: OROS-MPH benefit varied by site for reducing ADHD symptoms but not for improving smoking abstinence. SCIENTIFIC SIGNIFICANCE: Assessment of site-type effects can indicate the generalizability of findings from multisite trials and should be routinely incorporated in the design of multisite trials.

Zebrafish for the study of the biological effects of nicotine.

INTRODUCTION: Zebrafish are emerging as a powerful animal model for studying the molecular and physiological effects of nicotine exposure. The zebrafish have many advantageous physical characteristics, including small size, high fecundity rates, and externally developing transparent embryos. When combined with a battery of molecular-genetic tools and behavioral assays, these attributes enable studies to be conducted that are not practical using traditional animal models. METHODS: We reviewed the literature on the application of the zebrafish model as a preclinical model to study the biological effects of nicotine exposure. RESULTS: The identified studies used zebrafish to examine the effects of nicotine exposure on early development, addiction, anxiety, and learning. The methods used included green fluorescent protein-labeled proteins to track in vivo nicotine-altered neuron development, nicotine-conditioned place preference, and locomotive sensitization linked with high-throughput molecular and genetic screens and behavioral models of learning and stress response to nicotine. Data are presented on the complete homology of all known human neural nicotinic acetylcholine receptors in zebrafish and on the biological similarity of human and zebrafish dopaminergic signaling. CONCLUSIONS: Tobacco dependence remains a major health problem worldwide. Further understanding of the molecular effects of nicotine exposure and genetic contributions to dependence may lead to improvement in patient treatment strategies. While there are limitations to the use of zebrafish as a preclinical model, it should provide a valuable tool to complement existing model systems. The reviewed studies demonstrate the enormous opportunity zebrafish have to advance the science of nicotine and tobacco research.

Residential treatment compared with outpatient treatment for tobacco use and dependence.

OBJECTIVE: To compare the effectiveness of outpatient vs residential treatment for tobacco dependence in a large referral practice. PATIENTS AND METHODS: We analyzed data from 2 cohorts of cigarette smokers who received either comprehensive outpatient or intensive 8-day residential treatment for tobacco dependence between January 1, 2004, and December 31, 2007. Self-reported 7-day point prevalence abstinence from smoking at 6 months was obtained via telephone interview. Logistic regression was used to assess the likelihood of increased abstinence with residential treatment. RESULTS: Overall, 4327 cigarette smokers received comprehensive outpatient treatment for tobacco dependence, and 226 smokers received treatment in an intensive 8-day residential program. Compared with outpatients, residential patients smoked more cigarettes per day (mean ± SD, 31.1 ± 14.4 vs 21.2 ± 11.2), had more severe nicotine dependence (Fagerström Test for Nicotine Dependence score, 6.9 ± 2.0 vs 5.1 ± 2.3), and were more likely to have been treated for alcoholism (58/222 [26%] vs 649/4327 [15%]) or depression (124/222 [56%] vs 1817/4327 [42%]; P<.001 for all comparisons). The 6-month smoking abstinence rate was significantly higher for residential patients compared with outpatients (115/222 [52%] vs 1168/4327 [27%]; unadjusted odds ratio, 3.0; 95% confidence interval, 2.3-3.9), with similar findings after adjusting for baseline characteristics (adjusted odds ratio, 3.58; 95% confidence interval, 2.6-4.9). CONCLUSION: Compared with smokers who received outpatient treatment, those who received residential treatment had more severe tobacco dependence. Residential treatment for tobacco dependence was associated with a significantly greater odds of 6-month smoking abstinence compared with outpatient treatment among smokers in a referral clinic setting.

Methylphenidate for treating tobacco dependence in non-attention deficit hyperactivity disorder smokers: a pilot randomized placebo-controlled trial.

BACKGROUND: Methylphenidate blocks the re-uptake of dopamine by binding to the dopamine transporter in the presynaptic cell membrane and increases extracellular dopamine levels. Similarities in neuropsychologic effects between nicotine and methylphenidate make it an intriguing potential therapeutic option. Previous research of methylphenidate in smokers has suggested a possible beneficial effect for the relief of nicotine withdrawal symptoms, but showed no efficacy in helping smokers with attention deficit hyperactivity disorder (ADHD) to stop smoking. METHODS: To investigate potential efficacy for relieving nicotine withdrawal symptoms and promoting smoking abstinence, we conducted a randomized, double-blind, placebo-controlled, phase II study of once-a-day osmotic-release oral system methylphenidate (OROS-MPH, Concerta®) at a target dose of 54-mg/day for 8 weeks compared with placebo in 80 adult cigarette smokers. RESULTS: Of the 80 randomized subjects and median smoking rate was 20 cigarettes per day. At the end of the medication phase, the biochemically confirmed 7-day point prevalence smoking abstinence was 10% (4/40) for the placebo group and 2.5% (1/40) for the OROS-MPH group. Nicotine withdrawal was not found to differ significantly between treatment groups during the first 14 days following the start of medication prior to the target quit date (p = 0.464) or during the first 14 days following the target quit date (p = 0.786). CONCLUSION: We observed no evidence of efficacy of OROS-MPH to aid smokers to stop smoking. Although there are biologically plausible hypotheses that support the use of OROS-MPH for treating tobacco dependence, we found no evidence to support such hypotheses. In addition to no increase in smoking abstinence, we saw no effect of OROS-MPH for tobacco withdrawal symptom relief and no change in smoking rates was observed in the OROS-MPH group compared to the placebo group.

Willingness of cancer patients to help family members to quit smoking.

OBJECTIVES: The impact of social support on successful smoking cessation has been well documented. However, little is known about whether personal experience with cancer may motivate cancer survivors to support smoking cessation among their family members and friends. As a first step in this line of research, we sought to explore interest in playing a supportive role for smoking cessation as well as correlates of such interest among cancer survivors. METHODS: Cancer survivors undergoing radiation therapy (N=211) completed a 77-item pencil-paper questionnaire. A section of the survey assessed interest in helping a smoker quit and characteristics of the smoking social network member. Respondents provided information on their smoking status, medical status, and psychosocial and behavioral factors related to cigarette smoking. RESULTS: Over half of the respondents 114 (54%) reported having someone close to them (family member or friend) smoking cigarettes who they thought should quit. Of these respondents (44 females, 70 males) 78% (89/114) reported they were definitely or probably interested in helping a smoker quit. Nearly all respondents wanted to help a family member (typically an adult child). CONCLUSIONS: Results suggest the potential feasibility of engaging cancer survivors to help family members quit smoking. Research is needed to determine the optimal methods and timing for engaging the cancer patient to maximize positive effects and minimize potential harms.

Varenicline for tobacco dependence treatment in recovering alcohol-dependent smokers: an open-label pilot study.

The purpose of this study was to obtain preliminary evidence of the efficacy of a 12-week course of varenicline for 7-day point prevalence smoking abstinence among recovering alcohol-dependent smokers. We enrolled 32 smokers with 6 months or more of recovery from alcohol dependence in an open-label clinical trial. Participants received varenicline 1 mg twice daily and 12 weeks of behavioral counseling. Participants were 69% men, 94% Caucasian, and smoking an average of 20.3 ± 5.0 cigarettes per day. After 12 weeks of treatment, 31% were biochemically confirmed 7-day point prevalence abstinent from smoking and 28% had prolonged smoking abstinence (2 weeks after target quit date onward). The most common adverse effects were mild to moderate nausea (28%) and sleep disturbance (19%). No serious adverse events were reported. Varenicline may be a useful aid for treating tobacco dependence among smokers who are in stable recovery from alcohol dependence. Further study of this treatment is warranted.