Effective smoking cessation interventions have yet to be identified for alcohol-dependent smokers in early recovery, despite a high prevalence of smoking in this population, and documented difficulty in quitting. Congruent with the TRC theme of the complex substance use disorder patient with an emphasis on nicotine, the primary aim of this TRC component will be to determine the efficacy and cost-effectiveness of an intensive smoking cessation intervention that utilizes tailored extended cognitive-behavioral therapy (ECBT) and combination nicotine replacement (CNRT). To accomplish this objective, we propose a two-arm randomized clinical trial. In Study Arm 1, patients will receive ECBT and CNRT. CNRT will consist of transdermal nicotine patches (TDN) and adjuvant nicotine lozenges. The ECBT is a modified version of a manual-based 16-session extended treatment currently used in ongoing smoking cessation studies by TRC collaborators. In Study Arm 2, participants will receive standard care that involves referral to a free-standing smoking cessation program that provides brief counseling and TDN. W e will recruit 280 smokers who are enrolled in the Drug and Alcohol Treatment (DAT) programs at the San Francisco VA Medical Center (SFVAMC) and Santa Rosa VA Community-based Outpatient Clinic (CBOC). To be eligible, participants must be abstinent from alcohol for at least one week, but not more than 30 days. We will compare outcomes for the two study arms by assessing biochemically-validated point-prevalence smoking status at 3, 6, 9, and 12 months post-baseline and continuous abstinence over the 12-month follow-up. Expired-air carbon monoxide (CO) will be used to biochemically verify 7-day point prevalence abstinence. We will also conduct an economic analysis to determine the cost-effectiveness of the intensive intervention compared with usual care. We will also examine cross-relapse pattems during the follow-up period, assessing changes in mood states and use of tobacco, alcohol, and other drugs at 3, 6, 9, and 12 months.
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