The prevalence of smoking in patients presenting with alcohol problems can reach up to 80%, commonly with high nicotine dependence. Consequently, mortality and morbidity due to smoking are elevated in this population, being the first cause of mortality in recovered alcohol dependents.

Nicotine and alcohol have cross-tolerance, share common pathophysiological mechanisms, and are suggested to have combined effects on the reward circuit. Several studies have shown that a relevant percentage of patients with alcohol problems is willing to stop smoking and that a simultaneous treatment of smoking and alcohol do not jeopardize alcohol treatment outcomes.

However, some controversy has emerged concerning the best timing to start a smoking cessation intervention, simultaneous vs. delayed, in patients attending an alcohol treatment program. Patients with past alcohol problems can benefit from both brief and intensive smoking cessation interventions while patients with short-term abstinence from alcohol may need intensive and sustained treatments and also have lower quit rates than general population.

It is no longer possible to ignore smoking consumption in patients with alcohol and other substance dependencies. Tobacco use should always be screened and monitored. Brief advice to all patients and intervention for smoking cessation if deemed appropriate should be offered during alcohol treatment. Future research should study new medications targeting both substances trough the understanding of shared genetic and neurobiological mechanisms, as well as the improvement of tobacco cessation treatments to prevent the high prevalence of relapses in this population.