treatment. However, in smokers with recurrent MDD (two or more past episodes), CBT-D with ST resulted in significantly higher abstinence rates than ST alone (p = 0.02). In sum, adding CBT-D to usual smoking-cessation treatment is efficacious in smokers with a history of recurrent depression. Cognitive-behavioral therapy with an emphasis on group cohesion and social support (Ait-Daoud et al., 2006) and mood management combined with tobacco-cessation treatment and increased therapist time (Brown et al., 2001; Collie et al., 2006) also appear to be effective in smokers with recurrent depression.

Hall et al. (2006) conducted a comparison of a stepped-care intervention with a brief-contact intervention in smokers with current depression recruited from four mental-health outpatient clinics. The stepped-care intervention consisted of a computerized expert system based on the stage-of-change model and the option of receiving six 30-minute psychotherapy sessions that included mood-management training and medication (nicotine patch and/or bupropion). The brief-contact intervention included a smoking-treatment referral list and a packet of educational materials at the first visit. Abstinence rates at 12 and 18 months were higher in depressed smokers who received the stepped-care intervention than in the brief-contact controls (Hall et al., 2006).

An etiologic connection may exist between smoking and depression (Aubin, 2009; Kotov et al., 2008). The variation in symptoms of MDD may affect smoking-cessation outcomes (Burgess et al., 2002) in such a way that increasing depressive symptoms are associated with poorer cessation outcomes. Smokers with a history of MDD who were currently free from depression and not on antidepressant medication and who stopped smoking were at a significantly increased risk for a new episode of depression (OR, 7.17; 95% CI, 1.5–34.5) compared with those who were not abstinent. The risk persisted during the 6-month follow-up period (Glassman et al., 2001).

Alcohol Abuse and Dependence

It has been estimated that 80% of people who abuse or are dependent on alcohol are smokers (Sussman, 2002), and rates of tobacco use and nicotine dependence increase with alcohol consumption (Falk et al., 2006). Of importance for DoD is that the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions found that the co-use of alcohol and tobacco was highest in men and women 18–24 years old (Falk et al., 2006). However, although most alcoholics are interested in quitting tobacco at some point and some are concerned that doing so will make them drink more (Joseph et al., 2003), treatment for tobacco cessation is not routinely included in alcohol-treatment programs



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