Tobacco use and tobacco-related disease are highly prevalent among persons with opioid use disorders (OUD). Unfortunately, traditional evidence-based smoking cessation interventions have yielded low rates of tobacco abstinence in this group. The majority of trials evaluating smoking cessation treatment interventions among persons with OUD have relied on short-term interventions that do not account for the unique challenges faced by these smokers, specifically, establishing initial abstinence, adhering to evidence-based cessation treatments, and maintaining abstinence once active treatments cease. Long-term smoking cessation medication treatment approaches have shown promise in promoting cessation and decreasing relapse among individuals without OUD, however the applicability of extended medication approaches to smokers with OUD may be limited by poor adherence to smoking cessation medications. Though adherence to cessation medication is strongly associated with cessation success, adherence is especially challenging for persons with OUD. Opioid treatment program-based directly observed therapy (DOT) interventions improve clinical outcomes in HIV and TB, and our pilot data suggest that DOT varenicline is associated with increased smoking cessation medication adherence and may increase smoking cessation rates. We therefore propose a 2 x 2 factorial, randomized, double-blind, placebo-controlled trial to efficiently test two interventions: directly observed medication therapy, and long-term therapy with varenicline. Our analytic strategy will evaluate the milestones in smoking cessation?achieving initial abstinence, preventing lapse and preventing relapse-- necessary for long-term cessation, and evaluate theoretically-guided psychological and social factors and pharmacogenetic factors that influence these cessation processes. We will recruit 450 smokers with OUD from community-based, outpatient opioid treatment programs and test the following specific aims: (1) to test the efficacy of directly observed varenicline therapy compared to self-administered varenicline therapy on smoking cessation milestones, (2) to test the efficacy of long-term varenicline compared to short-term varenicline on smoking cessation milestones, and (3) to understand the mechanism of smoking cessation by examining the impact of theory-guided psychological and social factors and of pharmacogenetic factors on cessation milestones. This proposal is innovative, and addresses the challenges of both promoting and maintaining tobacco abstinence among smokers with OUD.

Public Health Relevance

Individuals with opioid use disorders use and suffer health consequences of tobacco at disproportionately high rates. Prior research suggests that opioid treatment patients can quit smoking while interventions are in place, but relapse and low medication adherence make sustained tobacco abstinence challenging. We propose to evaluate the mechanisms of two promising interventions to promote and maintain tobacco abstinence: directly observed therapy and long-term varenicline treatment. The proposed research will guide efforts to optimize medication treatment effects and reduce the burden of tobacco use among opioid treatment patients.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
Project #
Application #
Study Section
Interventions to Prevent and Treat Addictions Study Section (IPTA)
Program Officer
Su, Shelley
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Albert Einstein College of Medicine
United States
Zip Code