Smoking among people who use substances other than tobacco or who are in recovery

SMART Recovery Global Research Advisory Committee

Smoking among people who use substances other than tobacco or who are in recovery

High rates of smoking in people who use other substances

Despite large reductions in tobacco smoking over time in the broader community, some populations, including people who use other substances, have very high rates of smoking (1).

International research shows that in people who use substances other than tobacco, smoking rates range from 68% to 90% (2). The Table below shows the prevalence of daily smoking among people who use substances or experience mental health conditions in Australia (3).

Substance or mental health condition

Percentage daily smokers

Harmful use/dependence on drugs


Harmful use/dependence on alcohol


Schizophrenia related conditions


Bipolar affective disorder


Panic disorder


Post traumatic stress disorder


Attention deficit hyperactivity disorder


Phobic anxiety disorders


Anxiety disorder, including GAD


Obsessive compulsive disorder




General population


Poor health and early death associated with smoking (1)

People who use substances and/or who have mental health conditions have limited access to smoking interventions, longer durations of smoking, and lower rates of quitting. They are also far more likely to die from smoking related illnesses like cardiovascular disease, respiratory disease and cancer than as a result of their substance use or mental health conditions.

Smoking and substance use multiplies health risks (1)

Many of the health risks associated with tobacco and other substance use are multiplicative rather than simply additive. For example, the risk of oesophageal cancer is higher among heavy alcohol drinkers as a result of alcohol allowing tobacco toxins to penetrate more deeply. Similarly, there is evidence that smoking cannabis is a risk factor for many of the same illnesses as tobacco.

Addressing smoking does not worsen mental health or substance use (3)

Many people mistakenly believe that smoking is helpful for relieving or managing feelings of depression, anxiety, and stress. However, quitting smoking actually improves mental health, mood, and quality of life and does not worsen substance use.

Encouraging trends (3)

There are some encouraging trends showing reductions in rates of smoking. Several studies from the United States have shown increased quit rates over time among people with psychological distress and alcohol use disorder. Data from the two most recent Australian Bureau of Statistics Health Surveys show that daily smoking prevalence among those with non-psychotic disorders appears to have declined. For those with substance use problems, smoking declined from 62% (2011-2012) to 57.1% (2014-2015) in Australia.

Some good news about addressing smoking (3)

People with substance use disorders are motivated to quit! However, many people with substance use disorders lack confidence or are wary about tackling multiple substances at once.

Research in the United States showed that when provided with a tobacco free treatment environment, patients with substance use and mental health conditions can make the decision to quit tobacco, which in turn helps them to maintain their progress in addressing substance use.

While low mood can hinder quit attempts, people in an addiction treatment setting can successfully quit smoking regardless of current depressive symptoms.

In the United States, although lower than for people without the disorders, the smoking quit rates for people with alcohol use disorders has increased over time.

Perhaps most importantly, smoking interventions and cessation during substance use treatment appear to enhance rather than compromise long-term progress in addressing other drug use.

Changing smoking may assist changes in substance use (3)

A 2015 systematic review of smoking cessation interventions for adults in substance abuse treatment or recovery concluded that nicotine replacement therapy (NRT), behavioural support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders.

Some research indicates that drug treatment clients can successfully quit smoking at rates similar to the general population when given access to an intensive intervention.

Several studies suggest that varenicline (Champix/Chantix) may promote smoking changes and concurrently help reduce heavy drinking in people with alcohol use disorders.

For methadone maintenance patients, varenicline and NRT may be effective for promoting tobacco abstinence.

Strategies to address smoking (4)

Counselling plus use of medications to address smoking is better than either strategy alone. People with substance use disorders who also smoke generally need more comprehensive and longer counselling than others who smoke. Quitlines are available free in each state of Australia. GPs, psychologists and pharmacists are very experienced in providing help to people addressing their smoking.

Medications can help address smoking. Combination NRT, such as a nicotine patch plus another form of NRT like oral spray, lozenge, vaporizer or gum may be required to alleviate cravings and withdrawal symptoms. Champix/Chantix has been found to be helpful. The combination of a patch plus Champix/Chantix may be even more effective for some people.

People who smoke and are on buprenorphine or methadone maintenance have very low quit rates, even with medicines to address smoking. Alternative treatments need to be considered when people don’t find these methods effective. Electronic cigarettes may have a role here. A recent review concluded that electronic cigarettes can help those who smoke to quit and reduce cigarette consumption. The review also reported that electronic cigarettes were 95% less harmful than smoking tobacco. However, there is still quite a bit of controversy about their use, and long-term efficacy and safety data are not yet available.

How SMART Recovery can help you to address smoking

Many of the strategies helpful for addressing substance use are also useful in addressing smoking. These strategies include learning more about smoking and how to change behaviour, identifying triggers, avoiding high-risk situations, keeping motivated, making lifestyle changes, and stress management.

SMART Recovery employs mutual aid to assist people to try out these helpful strategies and others (‘change tools’). So, attending SMART Recovery groups online or face to face may help address smoking as well as other substance use, if that’s what you want to do.

As we pointed out above, medicines to help reduce cravings and withdrawal are also recommended as well as attending SMART Recovery groups. These may be helpful for some months or even longer, as you build confidence in addressing cravings without using tobacco.

If you are interested in attending a SMART Recovery group, come along or email if you would like to find out more.

See the link below to see Habib’s story from Cancer Council, Victoria, Australia.

Training is available for SMART Recovery facilitators

Quit Australia



  1. Australian Institute of Health and Welfare. Alcohol, tobacco and other drugs in Australia 16 April, 2021). Link to DOI:10.25816/c9x6-gy43
  2. Greenhalgh, EM, Bayly, M, Hanley-Jones, S. & Scollo, MS 1.10 Prevalence of smoking in other high-risk sub-groups of the population. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from

  3. Greenhalgh, EM., Jenkins, S, Stillman, S., & Ford, C. 7.12 Smoking and mental health. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from

  4. Mendelsohn, C.P. and Wodak, A. Smoking cessation in people with alcohol and other drug problems. Australian Family Physician, Vol.45, No.8, August 2016.