Smoking and Vaping in People With Substance Use Disorders

A major study of 2,652 adults with a substance use history in JAMA Psychiatry showed discontinuing smoking was strongly and positively associated with recovery from substance use disorders (SUDs). They also quantified the difference: Smoking discontinuation elevated the odds of substance abuse disorder (SUD) recovery by as much as 42 times, an impressive improvement.

In a National Institute on Drug Abuse (NIDA) news release, Dr. Nora Volkow, M.D., director of NIDA, said: “We now have strong evidence from a national sample that quitting cigarette smoking predicts improved recovery from other substance use disorders. It underscores the importance of addressing different addictions together, rather than in isolation.”

Dr. Wilson Compton, M.D., deputy director of NIDA and an author on the paper reporting the discovery, stated: “Although the health benefits of quitting smoking are well-known, smoking cessation has not been seen as a high priority in drug addiction treatment programs. These findings bolster support for including smoking cessation as part of addiction treatment.” Both Volkow and Compton emphasized that ending smoking should no longer be viewed as peripheral in SUD treatment.

Dr. Compton recommended FDA-approved treatments like nicotine replacement therapy (NRT), prescribed medications like varenicline (Chantix) and bupropion (Zyban), behavioral therapies, or repetitive transcranial magnetic stimulation (rTMS).

Déjà Vu All Over Again

Back in 2004, Judith J. Prochaska, Ph.D., M.P.H., and colleagues at UCSF did a meta-analysis of 19 clinical trials and discovered smoking-cessation interventions delivered during addiction treatment were associated with a 25% higher likelihood of long-term abstinence from alcohol/illicit drugs, directly countering the myth that quitting smoking harms SUD outcomes.

Even further back in 2003, Dr. Stephenie C. Lemon, M.D., and colleagues at Brown University studied adults in drug treatment. Among 2,316 smokers in drug treatment, smoking cessation during treatment was associated with greater drug abstinence 12 months after treatment completion. Despite drug abuse treatment programs' past hesitancy to encourage smokers to quit, smoking cessation does not negatively impact drug use outcomes. Instead, the reverse is true.

Looking Back in Time

In the early days of residential treatment in drug rehabilitation centers, facilities, including the Betty Ford Center, did not have smoke-free policies and focused on alcohol and illicit drugs. Conventional Alcoholics Anonymous wisdom back then held that quitting smoking during substance abuse treatment might interfere with recovery from other addictions. The belief that cigarette smoking should not be addressed when someone is admitted for alcohol use disorder (AUD) treatment has deep roots in early AA teachings and the addiction treatment culture that followed. The first generations of AA members, including co-founders Bill W. and Dr. Bob, were heavy smokers, and Dr. Bob died of cancer, and Bill W., a chain smoker, died of emphysema and pneumonia.

Alcohol was considered the “primary addiction.” Smoking became deeply embedded in AA meetings, treatment centers, and rehab culture. Alcoholism was seen as an immediate and life-threatening condition, while tobacco-related disease was thought to be a “longer-term” problem. Clinicians prioritized abstinence from alcohol above all else. I remember speaking at the Betty Ford Center on tobacco cessation in the '80s after it was clear people with AUD were more likely to die from tobacco-related illnesses than from alcohol itself. Nicotine is very addictive; it may take many quit attempts before stopping smoking for one full year. Nicotine-dependent people usually hear “you may need five to seven tries to quit,” but real-world averages suggest that dozens of attempts are typical before long-term tobacco cessation success. So, encourage quit attempts and trying. Most relapses occur early—clinicians should focus on relapse prevention, especially in the first six months. Only in the past two decades has there been a stronger push toward integrating tobacco cessation into addiction treatment.

The current policy reflects a move towards tobacco-free treatment centers, with staff and physicians encouraging cessation, although some designate outdoor areas for residential patients and family program participants. According to Alta DeRoo, M.D., former Naval Flight Officer, board-certified addiction medicine physician and obstetrician-gynecologist, and the chief medical officer of the Hazelden Betty Ford Foundation, “We do offer smoking cessation programming and we do prescribe NRT [nicotine replacement therapy] or anti-craving medications if a patient would like to stop smoking.”

Nicotine Is Much Like Other Drugs of Abuse

Nicotine is highly addictive—more so than alcohol, but less than heroin or cocaine, addictions which have many more slips and relapses than successes. Nicotine (from cigarettes and vaping) results in nicotine levels binding to nicotinic acetylcholine receptors (nAChRs). Each puff causes a small, rapid dopamine surge, reinforcing the act of inhalation, which stimulates dopamine release into the brain's nucleus accumbens (NAc). A smoker takes an average of 10 to 15 puffs per cigarette, delivering 1-2 mg of nicotine, making smoking a serious addiction. It’s no wonder that using a drug like nicotine interferes with alcohol or drug recovery, while ending such use improves the prognosis of recovery.

Smoking Essential Reads

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What About Vaping Nicotine?

A 2025 study by Streck and colleagues evaluated using e‑cigarettes versus conventional nicotine replacement therapy (cNRT) in adults with SUDs and found both options were safe and well tolerated—though the study did not directly assess SUD recovery outcomes. Nicotine and other drug cues can amplify each other, so it is important to address both nicotine vaping and tobacco smoking. Even reducing smoking may reduce cross-cue reactivity, triggering relapse from alcohol or opioids.

There is no strong, direct evidence indicating vaping nicotine improves SUD recovery—or doesn’t—though it may help some individuals quit combustible tobacco. The process of vaping cessation is challenging due to high nicotine concentration, rapid dosing, and often underestimated dependence—factors that can make quitting vaping more difficult than quitting cigarettes. Broader findings on e‑cigarettes suggest they expose users to fewer toxicants than combustible cigarettes, but long-term safety and efficacy in aiding recovery from other addictions remain uncertain.

However, for people with SUDs, caution is warranted, given the common denominator, nicotine in tobacco smoking and vaping, as we try to understand the short- and long-term potential to perpetuate neuroadaptations, cravings, and dependence during recovery, a time when neuroplastic healing is essential.

Conclusion

Tobacco smoking in people with SUDs is a leading cause of medical costs and death. Smoking cessation is critical in patients recovering from SUDs. Research has increasingly highlighted that all drugs, including nicotine, have common net effects on dopamine release. While they have essential differences, they also have commonalities in the brain's reinforcement pathways. The new data clearly show that smoking discontinuation improves the odds of SUD recovery by as much as 42 times. It also makes sense to end vaping nicotine as well.