Substance use disorder (SUD) patients face a dual addiction challenge: 84% smoke tobacco—more than double the general population’s rate (31%)—yet smoking cessation is rarely integrated into their primary addiction treatment 14. This gap persists despite tobacco being the leading cause of preventable death in this group, with smoking-related mortality often exceeding deaths from their primary substance of abuse 2. SUD patients experience compounded health risks, including severe respiratory diseases, cardiovascular damage, and accelerated mental health decline 18. As lead researcher Professor Billie Bonevski (Flinders University) notes: "Despite the immense health burden, tailored quit strategies for this group remain scarce"4.
The pioneering trial addressed this gap by recruiting 363 adult smokers exiting smoke-free alcohol/drug withdrawal facilities across Australia. Participants were randomized into two groups 24:
E-cigarette group: Received 12 weeks of nicotine e-cigarette devices.
Combination NRT group: Received 12 weeks of multiple nicotine replacement products (gum, lozenges, inhalers, oral sprays).
Both groups received proactive behavioral counseling via Quitline. Crucially, abstinence was verified through carbon monoxide breath testing and self-reporting at 9 months. The pragmatic design mirrored real-world clinical settings, enhancing applicability 2.
Equal efficacy: 11% of e-cigarette users and 10% of NRT users maintained continuous abstinence for 7+ months—a statistically equivalent result (RR 1.09; 95% CrI 0.52–1.89) 2.
Reduced harm: Both groups drastically cut daily cigarette consumption (from ~23 to ~11 cigarettes/day) 2.
Safety: Serious adverse events were rare and unrelated to treatments (15 in e-cigarette vs. 13 in NRT group) 2.
Notably, the 10% quit rate defies historical trends; SUD populations typically relapse within 24 hours post-discharge and show near-zero long-term cessation 24.
Contrary to studies in the general population—where e-cigarettes often outperform NRT—this trial found no advantage for either approach in SUD patients 29. Bonevski emphasizes: "This isn’t about one therapy beating another. Success hinges on systematically embedding cessation support into addiction recovery programs"14. Key clinical takeaways include:
Accessibility matters: Providing multiple FDA-approved NRT options (patches, gum, sprays) accommodates individual preferences and barriers 14.
Behavioral integration: Proactive counseling (e.g., Quitline) addresses psychological triggers linking substance cravings and smoking 28.
Timing is critical: Discharge from inpatient care is a "teachable moment"—patients are primed for behavioral change 2.
The study challenges healthcare systems to redesign SUD protocols:
Mandate cessation support: Make NRT/behavioral counseling standard in addiction rehabilitation, akin to treatments for alcohol or opioids 48.
Combat stigma: Frame smoking cessation as life-saving for SUD patients, not a "secondary" concern 14.
Long-term view: Even modest quit rates (10%) could prevent thousands of premature deaths given SUD patients’ extreme vulnerability to tobacco-linked diseases 210.
As Bonevski concludes: "Helping this group quit smoking saves lives—and now we know there’s more than one way to do it"
Equal efficacy: 11% of e-cigarette users and 10% of NRT users maintained continuous abstinence for 7+ months—a statistically equivalent result (RR 1.09; 95% CrI 0.52–1.89) 2.
Reduced harm: Both groups drastically cut daily cigarette consumption (from ~23 to ~11 cigarettes/day) 2.
Safety: Serious adverse events were rare and unrelated to treatments (15 in e-cigarette vs. 13 in NRT group) 2.
Notably, the 10% quit rate defies historical trends; SUD populations typically relapse within 24 hours post-discharge and show near-zero long-term cessation 24.
Contrary to studies in the general population—where e-cigarettes often outperform NRT—this trial found no advantage for either approach in SUD patients 29. Bonevski emphasizes: "This isn’t about one therapy beating another. Success hinges on systematically embedding cessation support into addiction recovery programs"14. Key clinical takeaways include:
Accessibility matters: Providing multiple FDA-approved NRT options (patches, gum, sprays) accommodates individual preferences and barriers 14.
Behavioral integration: Proactive counseling (e.g., Quitline) addresses psychological triggers linking substance cravings and smoking 28.
Timing is critical: Discharge from inpatient care is a "teachable moment"—patients are primed for behavioral change 2.
The study challenges healthcare systems to redesign SUD protocols:
Mandate cessation support: Make NRT/behavioral counseling standard in addiction rehabilitation, akin to treatments for alcohol or opioids 48.
Combat stigma: Frame smoking cessation as life-saving for SUD patients, not a "secondary" concern 14.
Long-term view: Even modest quit rates (10%) could prevent thousands of premature deaths given SUD patients’ extreme vulnerability to tobacco-linked diseases 210.
As Bonevski concludes: "Helping this group quit smoking saves lives—and now we know there’s more than one way to do it"