Highlight
– In a nationally representative longitudinal cohort (PATH Study), within-person change from current to former cigarette smoking was associated with 30% higher odds of sustained recovery from other substance use disorders (SUDs) year to year (OR 1.30; 95% CI, 1.07–1.57).
– The association persisted after a one-year lag (OR 1.43; 95% CI, 1.00–2.05) and in a second cohort (2016/2018–2022/2023) (OR 1.37; 95% CI, 1.13–1.66), suggesting temporal robustness.
– Findings support integrating evidence-based tobacco treatment into SUD care, rather than deferring smoking cessation until later in recovery.
Background: Clinical Context and Unmet Need
Tobacco dependence is a leading preventable cause of morbidity and mortality and remains highly prevalent among people with substance use disorders (SUDs). Cigarette smoking rates in SUD treatment populations are often several-fold higher than in the general population, contributing to disproportionate cardiovascular, pulmonary, and cancer-related burden. Despite clear health harms and available effective treatments for tobacco dependence, smoking cessation interventions are historically underused in SUD treatment settings because of concerns that quitting smoking will undermine recovery from other substances, limited organizational resources, and therapeutic priorities that focus on the primary substance of abuse.
Study Design and Methods
The paper by Parks et al. used data from the Population Assessment of Tobacco and Health (PATH) Study, an ongoing US nationally representative longitudinal cohort, to evaluate whether within-person changes in cigarette smoking status were associated with recovery from other SUDs over time. Primary analyses examined adults enrolled in the wave 1 cohort (recruited 2013/2014) with annual assessments through wave 4 (2016/2018); a second cohort recruited from 2016/2018 and followed to 2022/2023 was used in sensitivity analyses.
Key exposure: self-reported cigarette smoking categorized as never, former, or current. Primary outcome: SUD recovery operationalized using the Global Appraisal of Individual Needs–Short Screener (GAIN-SS) SUD subscale distinguishing respondents with high lifetime SUD symptoms (4–7 symptoms) who reported zero past-year symptoms (sustained remission) versus those with any past-year symptoms (current SUD or substance use).
Analytic approach: fixed-effects logistic regression was used to assess within-person changes, thereby controlling for time-invariant between-person confounders (e.g., genetic predisposition, baseline personality traits, socioeconomic background) and adjusting for measured time-varying covariates. The authors explored contemporaneous and lagged (1-year) relationships and replicated findings in a separate cohort.
Key Findings
In the main cohort (n = 2,652), the demographic profile included mean age ~39 years and a racially and ethnically diverse sample. The principal finding was that, within individuals, transitioning from current to former cigarette smoking between annual assessments was associated with higher odds of SUD recovery the same year. Specifically:
- Year-to-year change from current to former cigarette use was associated with a 30% increase in odds of achieving sustained remission from other SUDs (OR 1.30; 95% CI, 1.07–1.57).
- This association remained after lagging the smoking change by one year (OR 1.43; 95% CI, 1.00–2.05), supporting a temporal relationship where smoking cessation precedes measured recovery.
- Analyses in a second nationally representative cohort (2016/2018–2022/2023) produced similar results (OR 1.37; 95% CI, 1.13–1.66), strengthening external validity.
The authors adjusted for several time-varying confounders and used fixed-effects models to remove bias related to stable individual traits. The robustness across lagged analyses and cohorts suggests the observed association is not solely due to concurrent improvements in health-seeking behavior or other time-limited factors.
Clinical and Public Health Interpretation
These longitudinal, within-person findings add to a growing body of evidence that smoking cessation does not impede—and may actually support—recovery from other substance use disorders. The results are consistent with earlier meta-analytic work showing that integrating tobacco treatment with SUD interventions is associated with improved long-term substance use outcomes rather than harm (e.g., Prochaska et al., J Consult Clin Psychol, 2004).
From a clinical standpoint, this study offers reassurance to clinicians and programs that addressing tobacco dependence during SUD recovery is unlikely to undermine—and may help—sustained remission from other substances. It also underscores the missed opportunity in many treatment programs that do not systematically offer smoking cessation services.
Strengths of the Study
- Use of a large, nationally representative longitudinal cohort improves generalizability to the US adult population with a history of SUD.
- Fixed-effects models controlled for all time-invariant between-person confounders, focusing on within-person change and reducing bias from stable characteristics.
- Consistency across lagged analyses and a replication cohort supports the robustness and temporal plausibility of the association.
Limitations and Caveats
- Observational design cannot prove causality. Although fixed-effects models and lagged analyses strengthen causal inference, unmeasured time-varying confounders (e.g., concurrent psychosocial interventions, changes in housing or employment, initiation of pharmacotherapy for other SUDs) might contribute to both smoking cessation and SUD recovery.
- Smoking status and SUD symptoms were self-reported and subject to misclassification and recall bias. The GAIN-SS is a screening tool rather than a diagnostic interview; clinically adjudicated diagnoses and objective biological verification (e.g., cotinine) were not used.
- The study does not detail how smoking cessation was achieved (behavioral counseling, nicotine replacement therapy, varenicline, bupropion, e-cigarette use, or unassisted). The heterogeneity of cessation methods may have different implications for practice and safety.
- Subgroup analyses by primary substance (alcohol vs. opioids vs. stimulants) and severity of SUD were not the focus; differential effects may exist and merit further study.
- Pathways linking smoking cessation to improved recovery remain speculative—behavioral engagement, improved self-efficacy, reduced cue-induced relapse, or pharmacologic effects are plausible mechanisms that require experimental investigation.
Implications for Practice
Clinical programs treating SUD should consider the following actionable steps based on current evidence including the present study:
- Systematically assess tobacco use for all patients with SUD and document readiness to quit.
- Offer evidence-based tobacco cessation treatments (behavioral counseling plus FDA-approved pharmacotherapies such as nicotine replacement therapy, bupropion, or varenicline) as part of comprehensive SUD care, rather than deferring until later in recovery.
- Coordinate care across addiction medicine, primary care, and mental health services to monitor withdrawal, manage psychiatric comorbidities, and support adherence to cessation therapies.
- Address organizational barriers (staff training, reimbursement, program policies) and patient-level concerns (fear of jeopardizing sobriety) using patient education that quitting smoking is safe and may support recovery.
Research and Policy Priorities
Key gaps remain:
- Randomized trials that prioritize SUD recovery outcomes while testing specific smoking cessation interventions (e.g., varenicline vs. NRT with counseling) in diverse SUD populations are needed.
- Mechanistic studies to clarify how smoking cessation may facilitate recovery—whether via behavioral substitution, neurobiological recovery, or enhanced engagement with treatment—would inform intervention design.
- Evaluation of implementation strategies to integrate tobacco treatment into real-world SUD treatment settings and measurement of long-term morbidity and mortality benefits is essential for policy change.
Conclusion
The PATH Study analyses reported by Parks et al. provide compelling longitudinal evidence that transitioning from current to former cigarette smoking is associated with higher odds of sustained recovery from other substance use disorders. These findings reinforce the clinical imperative to offer evidence-based tobacco cessation to people in or recovering from SUDs and to dismantle historical barriers that have deferred addressing tobacco dependence. Integrating smoking cessation into routine SUD treatment may improve long-term health and recovery outcomes without compromising addiction recovery.
References
1. Parks MJ, Blanco C, Creamer MR, et al. Cigarette Smoking During Recovery From Substance Use Disorders. JAMA Psychiatry. 2025 Aug 13;82(10):1002–1008. doi:10.1001/jamapsychiatry.2025.1976.
2. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol. 2004;72(6):1144–1156. doi:10.1037/0022-006X.72.6.1144.
3. U.S. Department of Health and Human Services. The Health Consequences of Smoking — 50 Years of Progress. A Report of the Surgeon General. 2014.
4. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). 2018. Available from: https://www.drugabuse.gov
